Opioids are old friends to the health care professional. So much relief from pain and suffering can be attributed to the proper use of the opioid family that it saddens us there is a flipside of misuse and abuse that also occurs.
The term opioid use disorder (OUD) is the new diagnostic standard. It combines opioid dependence and opioid abuse, also pulling in the wide range of related opioid prescriptions and illicit chemicals. Though it may seem generic, opioid use disorder guidelines by the American Psychiatric Association express the expectation that the specific agent will be added to the diagnosis once identified – e.g., Opioid Use Disorder; Heroin, or, Opioid Use Disorder; Oxycontin, LAAM (Leo alpha acetylmethadol), or others.
Please remember substance use and abuse basics. Not everyone taking a particular medication or street substance is an addict. With opioids especially, the current trend in health care is to label anyone on prescription analgesics either an addict or an addict in the making. Opioids are an acceptable means of managing pain, both for short periods and long. It is an expectation that an individual utilizing them for legitimate reasons will, over time, begin to develop a physical tolerance for the medication, and upon abrupt discontinuation, experience withdrawal-type symptoms as their metabolism adjusts to the absence of the opioid. Neither tolerance nor withdrawal makes an addict. The DSM-5 emphasizes that the use of a substance does not make a person an addict.
The motivation for use has an important role for opioids. During an assessment, ask your client whether they gain benefit from their opioid beyond the relief of pain, feelings of well-being, euphoria, a feeling of relaxation, or a rise in mood beyond what may be attributed to pain relief. Frequently those who utilize opioids for the purpose of mood elevation or dissociation with current troubles will tell you outright if asked. Client survey tools such as the Current Opioid Misuse Measure (COMM) or Screener and Opioid Assessment for Patients with Pain (SOAPP) are available for use when client motivation for opioid use is uncertain.
Opioid Use Disorder focuses on the detrimental consequences of repeated opioid use along with an observable pattern of compulsion or cravings to use. OUD is only diagnosed when opioid use becomes persistent and causes significant educational, occupational or social impairment. Commonly abused opioids include heroin, codeine, fentanyl, morphine, opium, methadone, oxycodone, and hydrocodone.
Individuals with opioid use disorder may show no acute symptoms that would trigger an inquiry into that person’s health history. Opioid users may also appear intoxicated or show signs of substance withdrawal. Opioid intoxication may appear as slurred speech, the appearance of being sedated, and the presence of pinpoint pupils. Those who have developed a tolerance may show few acute signs of opioid intoxication. Ongoing use of opioids tends to lead to a look of general poor health and debilitation, though mild or moderate ongoing users may not have progressed to an appearance of reduced health.
Opioids may be ingested in many ways:
- Orally – either in solution or as tablets or powders
- Intranasal – “sniffing” or “snorting”
- Subcutaneous injection – “skin-popping”
- Intramuscular – “muscling”
- Intravenous – “mainlining” or “shooting up”
- Smoked – smoking opioids is the fastest way to the brain and is generally a mix of opioid with cannabis or tobacco
Opioids purchased illegally run the risk of contamination by improper handling or purposeful “cutting” or dilution of the substance by other compounds. Injection users run a high risk of infection, both localized and systemic. HIV, hepatitis B, and hepatitis C are all associated with opioid and other injectable substance use. Hepatitis C infection is also associated with intranasal inhalation of opioids and other substances, particularly in group settings where users pass around a shared beverage straw for snorting.47
Physical examination for suspected opioid intoxication or opioid poisoning should include a search for the classic signs of opioid overdose:
- Depressed mental status
- Decreased respiratory rate
- Decreased lung tidal volume
- Decreased bowel sounds
- Decreased (miotic – constricted) pupils
Drowsiness tends to follow the euphoria sought after by users of opioids, and the sedation effect may progress to a coma for some. Inattention resulting from perceptual changes and ability to concentrate may progress to ignoring potentially harmful events. In rare instances, intoxication may cause hallucinations with intact reality testing or auditory, visual or tactile illusions occurring in the absence of delirium.
For suspected acute opioid intoxication, laboratory studies should be included in the workup:
- Immediate blood glucose for hypoglycemia, a condition often mistaken for opioid intoxication.
- Serum acetaminophen concentration due to marketing prescription opioids in combination with acetaminophen leading to a heightened risk of acetaminophen hepatotoxicity.
- Serum creatine phosphokinase and electrolytes to exclude rhabdomyolysis (muscle breakdown) secondary to prolonged immobility, always a concern due to the intense sedative effects of opioids.
- Urine toxicology screens for opioids.
Some, but not all, individuals with opioid use disorder show positive for opioid drugs for 12-36 hours on routine urine toxicology tests. Opioids not detected by routine urine toxicology and must be specifically tested for are:
- Methadone, buprenorphine, and LAAM (which can be detected for several days to more than a week).
- Fentanyl (which can be detected for several days).
Please be aware 80 - 90% of injection opioid users screen positive for hepatitis A, B or C. HIV is prevalent especially amongst injection Heroin users.47
Opioid Intoxication, Diagnostic Criteria47
- Recent use of an opioid.
- Clinically significant problematic behavioral or psychological changes (e.g., euphoria followed by apathy, impaired judgment, dysphoria, psychomotor agitation or retardation) developed during or shortly after use.
- Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs or symptoms developing during, or shortly after, opioid use.
- Drowsiness or coma
- Slurred speech
- Impairment in attention or memory
Opioid intoxication diagnosis focuses on the presence of significant negative impact, psychological and behavioral changes accompanying or following substance use. The presence of alcohol or sedatives in the person’s system can muddy diagnosis, and therefore, a naloxone challenge may be administered. Naloxone is a short-acting opioid antagonist that temporarily counters the respiratory depressant and to a small degree, the sedative effects of opioids. Use of naloxone may put an opioid user suddenly into physical withdrawal, so caution should be used when administering.48
Opioid Withdrawal, Diagnostic Criteria48
- Presence of either of the following:
- Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer).
- Administration of an opioid antagonist after a period of opioid use
- Three (or more) of the following developing within minutes to several days after Criterion 1:
- Dysphoric mood
- Nausea or vomiting
- Muscle aches
- Lacrimation or rhinorrhea
- Pupillary dilation, sweating, or piloerection (raised or bristled hair on the back of neck or skin)
Opioid withdrawal can be a brutal affair, and contrary to conventional shared wisdom amongst health providers, opioid withdrawal can indeed be life-threatening. Withdrawal symptoms may begin immediately after the administration of an opioid antagonist (e.g., naloxone or naltrexone) or a partial opioid antagonist (e.g., buprenorphine). Stopping opioids after a prolonged period of use results in withdrawal symptoms around 6 hours after the last dose of a short-acting opioid, and up to 48 hours after stopping the longest acting opioid, methadone. The peak of withdrawal tends to be with 24-48 hours yet persists several days for the short-acting agents and up to 2 weeks for methadone, with sleep and mood disturbances often persisting for months. Many who have undergone opioid withdrawal compare it with the “worst case of flu imaginable” and with some justification as symptoms of withdrawal parallel those of food poisoning or the gastrointestinal effects of influenza. Muscle and abdominal cramping, nausea, diarrhea, runny nose, tearing eyes, dizziness and restlessness to name a few of the more common opioid withdrawal symptoms.
Opioid withdrawal is known to cause brief, but severe, episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose, particularly among those desperate to avoid withdrawal, is common and should not be mistaken for a suicide attempt.