Opioid Use Disorder in the New DSM-5

Medicare opioid abuse
Roel Smart / E+ / Getty Images

Opioid Use Disorder 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, the DSM-IV-TR, known as Opioid Dependence and Opioid Abuse, and incorporates 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 guidelines indicate that the actual opioid drug being used by the individual is specified in the diagnosis. There are a variety of different opioid drugs, ranging from street drugs such as heroin, to opioids used for the substitution of street drugs, such as methadone, which can be accessed through a bone fide methadone maintenance program or purchased illicitly, to analgesics used mainly in hospital settings, such as morphine, to common painkillers available on prescription, such as codeine and oxycontin. So 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 less than 10% of people aged 12-17 years old in the United States with Opioid Use Disorder take heroin. Most people with Opioid Use Disorder use analgesic opioids, or painkillers whether they are prescribed for themselves or for someone else, or obtained some other way.

Symptoms of Opioid Use Disorder

The diagnosis of Opioid Use Disorder can be applied 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.
  • Cravings 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?

No. Many people are prescribed opioids for pain, for long and short periods, and do not develop an opioid use disorder. And while it is often the case that people will develop a physical tolerance to prescribed opioids, and experience physical withdrawal symptoms if they do not take the drug, DSM-5 explicitly states that these are not applicable if the individual is experiencing these symptoms under appropriate medical supervision. Why? Because addictive disorders are primarily psychological in nature, and although someone can develop normal physical responses to prolonged drug exposure, that in itself does not constitute a disorder, if they have no cravings for the drug, no difficulty using appropriate dosages, and no lifestyle problems as a result of taking the drug (although someone in pain may have reduced activity as a result of their pain, that is not the same as reduced activity because they are seeking out opioid drugs.) This is a major step forward in the understanding of substance use disorders.

Neither does use of an illicit opioid drug such as heroin automatically mean that the individual has an Opioid Use Disorder. Since the 1970s, it has been known that a sub-population of heroin users are able to control their drug use and use without it causing harm to themselves or others. 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 nondrug users, rather than other heroin users.

While many problematic heroin users claim their use is non-problematic, typically heroin use causes more significant and long-lasting problems for users than the use of other drugs. The exact numbers of problematic and non-problematic heroin users are unknown, and because of the secrecy surrounding heroin use, so it is difficult to compare problematic and non-problematic users. It does appear 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 exactly why some people become addicted when they take opioids, while others do not.


There are several screening tools available that have been developed by experts in addiction and published so that others can use them. These screening tools can be used to determine whether someone is may need to be assessed for opioid use disorder. One very common use, a simple tool that is used to screen for substance use disorders is the CAGE questionnaire, which is easy to remember using the acronym CAGE as key letters in four revealing questions. If someone answers yes to any of these questions, they would benefit from a more complete assessment.

C - Stands for "cut down" - "Have you tried to cut down on your drinking or drug use, but couldn't?"

A - Stands for "annoyed" - "Are family and friends annoyed about your drinking or drug use?"

G - Stands for "guilty" - "Do you ever feel guilty about your drinking or drug use?"

E - Stands 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.

Was this page helpful?

Article Sources

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fifth edition, DSM-5TM. American Psychiatric Association. 2013.
  • Hser, Y., Evans, E., Huang, D., Brecht, M. and Li, L. "Comparing the dynamic course of heroin, cocaine, and methamphetamine use over 10 years." Addict Behav 33:1581-1598. 2008.
  • Powell, D. "A pilot study of occasional heroin users." Arch Gen Psychiatry 28 (4), pp. 586-94. 1973.
  • Sanchez, J., Chitwood, D. and Koo, D. "Risk Factors Associated with the Transition from Heroin Sniffing to Heroin Injection: A Street Addict Role Perspective." Journal of Urban Health 83:896-910. 2006.