Opioid use disorder: Clinical sciences

Chapters:

Watch video only

Introduction 0:00–1:19

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.

Unstable 1:19–2:31

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.

Stable 2:31–6:26

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.

DSM-5 criteria 6:26–8:35

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.
Now, if your patient meets two or more of these 11 criteria in the last 12 months, you can diagnose opioid use disorder!

Assess severity 8:35–8:52

Next, assess the severity of your patient’s opioid use disorder based on the number of criteria that are met. Okay, if your patient meets two or three of the DSM-5 criteria, diagnose mild opioid use disorder!

Mild opioid use disorder 8:52–12:47

The first step in management is counseling in the form of a brief intervention, usually during a routine outpatient encounter.
You should use motivational interviewing techniques, like asking open-ended questions, which helps patients develop insight into the effects of their opioid use.
Patients with mild opioid use disorder may also benefit from individual or group counseling. Commonly used techniques include cognitive-behavioral therapy, or CBT, with additional support from groups like Narcotics Anonymous, or NA.
In addition, be sure to treat associated medical conditions, such as opioid-induced constipation or blood-borne infections!
Lastly, consider offering pharmacologic therapy to support the patient’s abstinence and reduce the risk of relapse. Three commonly used medications include methadone, buprenorphine, and naltrexone.
These medications have effects on the opioid receptor that help decrease opioid cravings; while methadone and buprenorphine also prevent withdrawal symptoms.
Additionally, buprenorphine and naltrexone block the action of other opioids at the receptor, potentially preventing euphoric effects and overdose.
Let’s go a little deeper! Methadone is a long-acting full opioid receptor agonist that occupies the opioid receptor, keeping people out of withdrawal with daily dosing in most cases.
Thus, methadone is most appropriate for individuals taking high daily doses of opioids or engaging in high-risk behaviors, such as IV substance use.
However, it has the highest potential for overdose. Laws created out of fear of risky use and diversion require initiation and titration of methadone must take place in a medically supervised setting until a maintenance dose is reached.
Once the patient demonstrates abstinence and adherence to an aftercare program, they may be prescribed methadone to administer on their own.
Next up is buprenorphine, which is a partial opioid receptor agonist, producing some opioid effect, though not enough to deliver the dangers of a full agonist, and preventing other opioids from having an effect.
Thus, buprenorphine has less potential for overdose. However, keep in mind that buprenorphine has a stronger binding affinity, so it can displace other opioids from the receptor and precipitate withdrawal.
In other words, the first dose of this medication should generally be given once the patient is experiencing withdrawal symptoms, or if the patient has been abstinent and no longer has opioids in their system.
Finally, naltrexone is an opioid receptor antagonist that simply blocks the ability of other opioids to have an effect and produces no opioid effect.
Thus, naltrexone reduces the positive effects of opioids and helps reduce cravings. Naltrexone will also precipitate withdrawal symptoms, so it’s generally used once a patient's withdrawal symptoms resolve or have been abstinent from opioids for a period of time.
Next, if your patient meets four or five of the DSM-5 criteria, diagnose moderate opioid use disorder. Again, these patients will benefit from counseling, either in an individual or group setting, and they could benefit from a recovery program, either in an inpatient or outpatient setting.

Moderate opioid use disorder 12:47–13:57

Inpatient opioid recovery programs provide a medically supervised environment for safe opioid withdrawal management, and provides education on opioid use disorders and access to specialists, such as addiction specialists and licensed chemical dependency counselors.
On the flip side, outpatient recovery programs are less structured and do not usually include medically supervised withdrawal.
Instead, these programs focus on education and group activities with others in recovery. In addition, don’t forget to treat any associated medical conditions, and offer pharmacologic therapy to support the patient’s abstinence and reduce the risk of relapse.
Finally, if your patient meets six or more of the DSM-5 criteria, diagnose severe opioid use disorder. Similar to patients with mild and moderate opioid use disorder, these patients will benefit from counseling and recovery programs.

Severe opioid use disorder 13:57–14:48

And again, be sure to treat any associated medical conditions and offer pharmacologic therapy! Let’s wrap this up with a clinical pearl!
For all patients, the risks of bad outcomes from drug use should be mitigated. These patients should all be prescribed naloxone, and those who inject should be counseled on how to obtain clean supplies to decrease the risk of hepatitis C, HIV, and acute infections.
Alright, as a quick recap… If an unstable patient presents with a chief concern suggesting opioid use disorder, stabilize the airway, breathing, and circulation, and immediately administer naloxone!

Review 14:48–15:41

On the other hand, for stable patients, first assess for substance use with a screening test, such as the DAST-10. If the screening test is positive, and the patient meets two or more of the DSM-5 criteria, diagnose opioid use disorder!
All individuals with opioid use disorder benefit from counseling and the treatment of associated conditions. Additionally, encourage recovery programs, as well as pharmacologic therapy with medications such as methadone, buprenorphine, and naltrexone.