Opioid Use Disorder in the New DSM-5

Medicare opioid abuse
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Opioid use disorder (also referred to as opioid addiction) is a diagnosis that was introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnosis combines two disorders from the previous edition of the DSM (DSM-IV-TR): opioid dependence and opioid abuse.

The DSM-5 diagnosis of opioid use disorder includes a wide range of illicit and prescribed drugs of the opioid class.

Although the generic term "opioid" is given in the DSM-5, the diagnostic guidelines indicate that the actual opioid drug being used by the individual should be specified in the diagnosis. For example, a person who has developed heroin addiction would be diagnosed with heroin use disorder.

Types of Opioids

Opioids are a drug class that acts on opioid receptors in the brain. They come in many forms, including:

  • Analgesics used mainly in hospital settings such as morphine (brand names include Roxanol-T and Avinza)
  • Illicit drugs such as heroin
  • Painkillers that are available with a prescription such as Abstral, Actiq, Onsolis, Fentora, Sublimaze (fentanyl); Oxycontin, Xtampza ER, Oxaydo (oxycodone); Vicodin, Hyslinga, Zohydro (hydrocodone); Dilaudid (hydromorphone); and codeine
  • Substitution drugs used to treat addiction to other opioids such as methadone

Opioid use disorder covers a range of drugs that can be accessed by people from different walks of life and from various sources. One of the most well-known opioid use disorders is heroin use disorder. Yet in 2017, an estimated 1.7 million Americans were living with substance use disorders related to prescription opioids (compared to 652,000 with a heroin use disorder).

Symptoms of Opioid Use Disorder

Opioid use disorder is a specific diagnosis. The diagnosis applies to a person who uses opioid drugs and has at least two of the following symptoms within a 12-month period:

  • Continuing to use opioids, despite the use of the drug causing relationship or social problems
  • Craving opioids
  • Failing to carry out important roles at home, work, or school because of opioid use
  • Giving up or reducing other activities because of opioid use
  • Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway
  • Spending a lot of time seeking, obtaining, taking, or recovering from the effects of opioid drugs
  • Taking more opioid drugs than intended
  • Tolerance for opioids
  • Using opioids even when it is physically unsafe
  • Wanting or trying to control opioid drug use without success
  • Withdrawal symptoms when opioids are not taken

If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our National Helpline Database.

Can Anyone Taking Opioids Have Opioid Use Disorder?

People can develop a physical tolerance to prescribed opioids and experience a physical withdrawal without the drug. However, the DSM-5 explicitly states that if an individual is experiencing symptoms while taking opioids under appropriate medical supervision, it is not an opioid use disorder.

Addictive disorders are primarily psychological in nature. If a person develops a normal physical response to prolonged drug exposure, this response in itself does not constitute a use disorder.

This is particularly true when a person does not have cravings for the drug, does not have difficulty using appropriate dosages, and does not experience any lifestyle problems caused by taking the drug.

The distinction is important because a person who is taking opioids as prescribed after a surgery or injury might have reduced activity because of pain and the need for healing, but this is not the same as reduced activity related to seeking out or using opioid drugs.

It's also not always the case that using an illicit opioid drug such as heroin means a person has an opioid use disorder. Since the 1970s, it has been known that there is a sub-population of heroin users who do not develop heroin use disorder.

The differences between people who use heroin and develop a use disorder and those who do not are related to several factors. Individuals who do not develop use disorder have been found to:

  • Cut back or stop as soon as they feel tolerance developing
  • Keep their drug use separate from their social life (socializing mainly with non-drug users rather than other heroin users)
  • Regulate their drug use
  • Use comparatively "safer" methods of taking the drug

Even though many people who use heroin claim that their use is non-problematic, heroin causes more significant and long-lasting problems for people who use it compared to other drugs.

Research seems to indicate that people who develop heroin use disorder tended to have significant mental health concerns even before they start using the drug. The people who do not develop use disorder tended to be more healthy psychologically and socially prior to use. More research is needed to see if these factors could also apply to people who do not become addicted to opioid pain medication.

Screening for Opioid Use Disorder

Experts have developed screening tools to assess a person's risk for use disorders Some of the tools are publicly available and can be used to determine if someone might need to be assessed for opioid use disorder.

CAGE Questionnaire

The CAGE questionnaire is a common and simple tool that can be used to screen a person for substance use disorders.

CAGE is an acronym pertaining to specific words in each of the tool's four questions:

  1. Have you ever felt you should cut down on your drinking?
  2. Have people annoyed you by criticizing your drinking?
  3. Have you ever felt bad or guilty about your drinking?
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? 

If a person answers "Yes" to any of the questions, they would benefit from a more complete assessment.

The opioid risk tool is a more complex assessment that calculates the factors that place individuals at greater risk of having a substance use disorder. Having a past family and personal history of substance use, a history of childhood sexual abuse, and a history of past or present psychological disorders (including depression and schizophrenia), as well as a person's age, are all associated with an increased risk for substance use disorders.

A Word From Verywell

If you think a loved one might have an opioid use disorder, you can encourage them to get the help they need by using techniques like open-ended questioning to have a respectful conversation about your concerns. You might need to enlist the help of others, such as a mental health professional or healthcare provider.

If a loved one is misusing opioids, learn how to administer Narcan (naloxone) and have it on hand in the event of an emergency. The medication can reverse a potentially fatal opioid overdose. You don't need a prescription to get Narcan—you can get it directly from a pharmacy.

If you are concerned about your own opioid use, reach out to your support network and have a frank conversation with your healthcare provider. If you are not already working with a counselor or therapist, ask your provider for a referral to a clinician or treatment program.

5 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Institute on Drug Abuse. Opioid Overdose Crisis.

  2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Opioid Use Disorder: Diagnostic Criteria. 2013.

  3. American Society of Addiction Medicine. DSM-5 Criteria for Diagnosis of Opioid Use Disorder.

  4. Powell DH. A pilot study of occasional heroin users. Arch Gen Psychiatry. 1973;28(4):586-94.

  5. SAMHSA-HRSA Center for Integrated Health Solutions. Screening Tools.

Additional Reading

By Elizabeth Hartney, BSc, MSc, MA, PhD
Elizabeth Hartney, BSc, MSc, MA, PhD is a psychologist, professor, and Director of the Centre for Health Leadership and Research at Royal Roads University, Canada.