Opioid use disorder: Clinical sciences

Opioid use disorder is a medical condition characterized by the inability to control the use of opioids, despite adverse health and social consequences. The cause of opioid use disorder is multifactorial, including psychological, biological, social, and environmental factors. Based on criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, or DSM-5, you can categorize opioid use disorder as mild, moderate, or severe.

Keep in mind that the terms opiates and opioids are sometimes used interchangeably, but they actually refer to different entities. Opiates refer to only naturally occurring compounds derived from the poppy plant like heroin, morphine, and codeine, all of which have agonistic effects on the opiate receptor.

On the flip side, opioids refer to synthetic and semisynthetic compounds that resemble opiates in structure and their effects on the opioid receptor.

Okay, if a patient presents with a chief concern suggesting opioid use disorder, first perform an ABCDE assessment to determine if the patient is unstable or stable. If your patient is unstable, stabilize the airway, breathing, and circulation, which might require endotracheal intubation with mechanical ventilation. Next, obtain IV access and put your patient on continuous vital sign monitoring including blood pressure, heart rate, pulse oximetry, and cardiac telemetry. In severe cases, opioid overdose can result in CNS depression, coma, and even death. In these patients, immediately administer the opioid antagonist naloxone to reverse the effects of an opioid overdose!

Here’s a clinical pearl to keep in mind! Severe withdrawal can lead to unstable vital signs, and even lethal electrolyte abnormalities from vomiting.

Now that we’ve addressed unstable patients, let’s return to the ABCDE assessment. If the patient is stable, first obtain a focused history and physical exam. Next, assess for substance use with a screening test, such as the Drug Abuse Screening Test, or DAST-10. DAST-10 contains ten “yes” and “no” questions about substance use over the past 12 months, including illicit drugs, prescription and over-the-counter medication. However, keep in mind that this screening test excludes alcohol use.

Here’s a high-yield fact! If you suspect your patient is using more than one substance, including alcohol, you might want to use the ASSIST questionnaire, which stands for Alcohol, Smoking, and Substance Involvement Screening Test. This is an eight-question test that identifies misused substances, such as tobacco, alcohol, cannabis, cocaine, stimulants, inhalants, sedatives, hallucinogens, and opioids. Alternatively, you can use the shorter SUBS screening test, which stands for Substance Use Brief Screen, that asks about tobacco, alcohol, illegal drugs, and prescription medications, including opioids.

Your patient or their close contact may report euphoria or confusion, as well as gastrointestinal symptoms like nausea and constipation. Also, they might have concerns about their opioid use, but keep in mind that, despite obvious signs, many patients may fear consequences and thus conceal issues related to their opioid use. Some individuals may deny or minimize the negative impact of opioid use, such as strained friendships or difficulties with co-workers.

Sometimes, there might be a history of a mood or personality disorder, such as depression or borderline personality disorder, which is also known as emotionally unstable personality disorder, or childhood trauma, such as parental abandonment. Family history may reveal opioid or other substance use disorders.

Physical examination might reveal decreased responsiveness, decreased body temperature, bradycardia, and abnormal blood pressure. You might notice pinpoint pupils, as well as needle puncture marks on the skin or nasal septal damage. But, in some cases, your patient’s examination might be completely normal. Finally, if the DAST-10 score is three or more, you should suspect opioid use disorder!

Here’s a clinical pearl! Opioids are either ingested, snorted, smoked, or injected by needle intravenously or subcutaneously. Injection opioid users are at risk of infections, including bacterial skin infections, solid organ abscesses, endocarditis, and even sepsis! Moreover, needle sharing increases the risk of blood-borne infections like HIV and hepatitis B and C. So, don’t forget to screen for these infections once you suspect opioid use, and be sure to refer patients to sources where they can obtain clean supplies.

Okay, once you suspect opioid use disorder (AUD), assess the DSM-5 criteria for opioid use disorder. The DSM-5 lists eleven criteria of opioid use disorder that falls into four general categories including impaired control, physical dependence, social problems, and risky use.

First, let’s discuss factors suggesting impaired control, like if your patient is using more opioids than intended or for a longer duration than intended. Next, they might be spending more time obtaining, consuming, or recovering from opioids; or they continue to use them despite insight that opioids are causing problems, like after legal consequences.

Next up is physical dependence. For example, the patient might report cravings for opioids; have unsuccessful attempts to decrease or stop using opioids; or even develop withdrawal symptoms, such as tremor or restlessness. Additionally, over time, your patient could develop tolerance, which means they have to use more opioids to reach the desired effect.

Now, social problems are apparent if your patient has reduced or given up important daily activities, like their favorite hobby or even personal hygiene. Other important social problems include failing to fulfill major obligations, such as work-related or parenting responsibilities; or continuing to consume opioids despite these social and interpersonal problems.

Finally, risky use refers to opioid use in physically hazardous situations, like operating a motor vehicle, using opioids while another person is under their care, or even consuming opioids on the job.