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Opioid Use Disorder (OUD)

BASICS

Description

  • Chronic illness involving misuse of prescription or illicit opioids (e.g., heroin)
  • Leads to CNS depression, euphoria, and can result in self-harm, overdose, and death
  • Includes prescription misuse and illicit use

EPIDEMIOLOGY

  • 2018: ~10.25 million people reported opioid misuse in the US (3.7% ≥12 yrs)
  • DSM-5 OUD diagnosis: 2.0 million (0.7% ≥12 yrs)
  • High mortality: In 2017, 47,600 died of opioid-related overdose in the US

RISK FACTORS

  • Prior substance use disorder
  • Severe pain
  • Co-occurring mental disorders (mood, PTSD, personality)
  • Social and environmental factors

GENERAL PREVENTION

  • Reduced opioid prescribing (down 29% from 2006–2018)
  • Harm reduction: clean needle exchanges, safe injection sites, naloxone access

COMMONLY ASSOCIATED CONDITIONS

  • Mood/personality disorders, PTSD, other substance use disorders
  • Infectious risks: Hepatitis A/B/C, HIV, STIs

DIAGNOSIS

History

  • DSM-5: At least 2 of following in 12 months:
  • Larger amounts/longer duration than intended
  • Strong craving or desire to use
  • Much time spent obtaining/using/recovering
  • Unsuccessful efforts to cut down
  • Continued use despite interpersonal problems
  • Failure to fulfill major obligations
  • Reduced social/occupational/recreational activities
  • Use despite physical/psychological problems
  • Use in hazardous situations
  • Tolerance
  • Withdrawal

Physical Exam

  • Not required for diagnosis, but helps distinguish dependence vs. use disorder
  • Tolerance: need for higher doses, or reduced effect at same dose
  • Withdrawal: pain, sweating, restlessness, pupil dilation, tremor, diarrhea, anxiety

Differential Diagnosis

  • Physical dependence (not OUD alone)
  • Mood/psychotic disorders, trauma, other SUDs, polysubstance use

Diagnostic Tests

  • Clinical diagnosis; consider prescription drug monitoring, urine/saliva drug screens

TREATMENT

General Measures

  • Medications for OUD (MOUD) + psychosocial therapy
  • Naloxone (Narcan): prescribe to all patients (and acquaintances)
  • Reverses opioid overdose rapidly, minimal side effects if given unnecessarily

First Line Medication

  • Opioid agonists:
  • Methadone: long-acting full agonist, once-daily, dispensed at specialty sites
  • Buprenorphine: partial mu-agonist; available as films/tablets/implant/injectable; often combined with naloxone (Suboxone) to deter misuse
  • Opioid antagonists:
  • Naltrexone: oral/injectable; must be opioid-free 1 week to avoid withdrawal
  • Injectable buprenorphine now widely used

Pregnancy Considerations

  • Risk of neonatal abstinence syndrome (NAS)
  • OUD in pregnancy requires tailored management and monitoring of newborns for NAS

Additional Therapies

  • Individualized psychosocial interventions recommended, but patient autonomy respected

Admission/Inpatient Considerations

  • Pain management is complex, may require higher opioid doses or alternative agents

ONGOING CARE

Patient Education

  • Harm reduction: clean needles, avoid IV use when possible, always have naloxone available
  • Family/friends: brief training on naloxone use

Prognosis

  • High mortality due to overdose and medical complications; most deaths are unintentional

ICD-10 Codes

  • F11.10: Opioid abuse, uncomplicated
  • F11.90: Opioid use, unspecified, uncomplicated
  • F11.1: Opioid abuse

Clinical Pearls

  • Treatment = Medications (MOUD) + psychosocial therapies
  • Prescribe naloxone to all OUD patients and their close contacts
  • Harm reduction and MAT both reduce mortality and improve outcomes