Opioid Use Disorder in the New DSM-5

Medicare opioid abuse
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Opioid use disorder (also known as opioid addiction) is a diagnosis introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It combines two disorders from the previous edition of the Diagnostic and Statistical Manual (DSM-IV-TR) known as opioid dependence and opioid abuse and includes a wide range of illicit and prescribed drugs of the opioid class.

Although the generic term, opioid use disorder, is given in the DSM-5, the diagnostic guidelines indicate that the actual opioid drug being used by the individual is specified in the diagnosis.

Types of Opioids

  • Street drugs such as heroin
  • Opioids used for the substitution of street drugs, such as methadone, which may be obtained through a methadone maintenance program or purchased illegally
  • Analgesics used mainly in hospital settings, such as morphine (brand names: Roxanol-T, Avinza)
  • Painkillers available on prescription, such as Abstral (fentanyl), Actiq (fentanyl), codeine, Dilaudid (hydromorphone), Fentora (fentanyl), Hyslinga (hydrocodone), Onsolis (fentanyl), Oxaydo (oxycodone), Oxycontin (oxycodone), Sublimaze (fentanyl), Xtampza ER (oxycodone), and Zohydro ER (hydrocodone).

Opioid use disorder covers a wide range of drugs accessed through many different sources, and by people of many different walks of life.

Probably the most well-known and notorious type of opioid use disorder is heroin use disorder, yet in 2017, an estimated 1.7 million Americans lived with substance use disorders related to prescription opioids, compared to 652,000 with a heroin use disorder.

Symptoms of Opioid Use Disorder

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

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

Does Anyone on Opioids Have Opioid Use Disorder?

While often people will develop a physical tolerance to prescribed opioids and experience a physical withdrawal without the drug, DSM-5 explicitly states that it is not an opioid use disorder if the individual is experiencing these symptoms under appropriate medical supervision.

Many people are prescribed opioids for pain, for long and short periods, and do not develop an opioid use disorder.

Because addictive disorders are primarily psychological in nature, even if someone develops a normal physical response to prolonged drug exposure, that in itself does not constitute a disorder. This is especially true if they have no cravings for the drug, no difficulty using appropriate dosages, and no lifestyle problems as a result of taking the drug (someone in pain may have reduced activity as a result of their pain, but that is not the same as reduced activity because of seeking out opioid drugs). This is a major step forward in the understanding of substance use disorders.

Using an illicit opioid drug such as heroin does not automatically mean that the individual has an opioid use disorder either. Since the 1970s, it has been known that a sub-population of heroin users who do not develop heroin use disorder. What makes the difference for these heroin users compared to those who have significant problems? They regulate their drug use, use safer methods of taking the drug, cutting back or stopping as soon as they feel tolerance developing, and they tend to keep their drug use separate from their social life, socializing mainly with non-drug users, rather than other heroin users.

While many heroin users claim their use is non-problematic, typically heroin use causes more significant and long-lasting problems for users than other drugs do. It appears that those who develop heroin use disorder have very significant psychological problems even before they start using the drug. In contrast, those who are able to control and manage their use tend to be more psychologically healthy and socially advantaged prior to use. The same may be true of those who do or do not become addicted to pain medication, but much more research is needed to understand this.

Screening for Opioid Use Disorder

Substance use disorder experts have developed several screening tools that are publicly available. These tools can be used to determine whether someone may need to be assessed for opioid use disorder. One very common use is the CAGE questionnaire, a simple tool that is used to screen for substance use disorders. If someone answers yes to any of these questions, they would benefit from a more complete assessment.

CAGE Questionnaire

  • C for "cut down": Have you tried to cut down on your drinking or drug use, but couldn't
  • A for "annoyed": Are family and friends annoyed about your drinking or drug use?
  • G for "guilty": Do you ever feel guilty about your drinking or drug use?
  • E for "eye-opener": Do you have a drink or use drugs as an "eye-opener" in the morning?

A more complex screening tool is the opioid risk tool, which calculates the factors that place individuals at greater risk of having a substance use disorder. These factors include past family and personal history of substance use, a history of childhood sexual abuse, age, and history of past or present psychological disorders, including depression and schizophrenia.

A Word from Verywell

If you think you or a loved one may be struggling with opioid use disorder, be sure to have Narcan (naloxone) on hand in case of emergency. This medication can stop a potential overdose, and you can get it directly from your pharmacy without a prescription. Encourage your loved one to get help by using techniques like open-ended questioning to have a respectful conversation. If this doesn't work, you may want to talk to their doctor. If it's your own use you're worried about, have an open and honest conversation with your doctor about your concerns.

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Article Sources

  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"

  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