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Opioid use disorder
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Opioid use disorder

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Contributors: Shea A. Nagle BA, Michael W. Winter MD
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Synopsis

Opioid analgesics are a class of medications prescribed to provide relief from moderate to severe pain (which may be acute or chronic) caused by trauma, postoperative pain, and malignancy. Opioids are derived from poppy plants, although they can also be synthetic and semisynthetic. In addition to analgesia, opioids can induce euphoria.

Opioids posit a high potential for dependence and abuse. Most opioids are classified as Schedule II substances according to the US Controlled Substances Act. Physicians should exercise extreme caution before prescribing opioids for patients, given their significant abuse potential and adverse side-effect profile. Resources for opioid prescribing guidelines, as well as nonopioid alternatives, can be found here.

Opioid drugs include morphine and codeine (natural opiates); heroin, oxycodone, oxymorphone, hydrocodone, hydromorphone, and buprenorphine (semisynthetic opioids); and meperidine (Demerol), fentanyl and fentanyl analogs such as carfentanil, and methadone (synthetic opioids). Routes of drug administration include oral, inhalation (smoking), intranasal (snorting), subcutaneous ("skin popping"), and intravenous.

Opioid use disorder is the habitual use of any substances within the opioid class of drugs leading to a state of opioid intoxication and/or dysfunctional behavior, with significant long-term adverse effects. The disorder can range from mild to severe. The individual may experience a growing tolerance and onset of withdrawal symptoms. Opioid withdrawal syndrome may present with profuse sweating, hypertension, nausea, vomiting, fever, anxiety, and lacrimation. (For discussion of withdrawal symptoms in neonates due to maternal use of opioids during pregnancy, see Neonatal abstinence syndrome.)

Opioid use disorder is a growing epidemic in the United States, with rates of use and overdose rising significantly every year. In 2015, it was estimated that 2.6 million people over 12 years of age were addicted to opioids. Patients dependent on opioid pain medications who are unable to obtain prescriptions legally may pursue opioids through alternate means. Persons using diverted opioids or street drugs face a greater risk of overdose and death due to inconsistency of strength / dosage, drug interactions, or contamination of supply. Newer strains of synthetic opioids or contaminated street drugs are more resistant to naloxone (Narcan) rescue treatments, thus increasing the lethality of opioid overdose.

Note: Children of parents with opioid use disorder are at increased risk for neglect and/or abuse.

Codes

ICD10CM:
F11.20 – Opioid dependence, uncomplicated

SNOMEDCT:
5602001 – Opioid abuse

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Polysubstance use disorder – Patients using opioids are at risk for other substance use disorders.

Intoxication / overdose from other drugs or medications:
  • Ethanol, methanol, ethylene glycol, etc
  • Benzodiazepines
  • Barbiturates
  • Clonidine
  • Organophosphates
  • Phencyclidine (PCP)
  • Sedative-hypnotic drugs – zolpidem, zaleplon, eszopiclone, etc
  • Antidepressants – selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclics, etc (see serotonin syndrome)
  • Antihistamines (see anticholinergic syndrome)
Respiratory failure – Decreased respiratory drive secondary to a nonopioid-related cause, such as trauma, increased cranial pressure, and hypercarbic respiratory failure.

Seizure – Consider as alternative cause of loss of consciousness.

Possible other causes of altered mental status / unresponsiveness – cerebrovascular accident, diabetic ketoacidosis, cardiac arrhythmia, myocardial infarction, hepatic encephalopathy, uremia, dementia, delirium, severe sepsis

Secondary infections

Endocarditis – Opioid users are at increased risk for bloodborne infections, including MRSA, that may result in endocarditis.

HIV / AIDS, hepatitis B, hepatitis C, syphilis – Intravenous drug use puts individuals at risk for contracting bloodborne infections.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed: 11/04/2019
Last Updated: 11/22/2019
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Opioid use disorder
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Opioid use disorder (Acute Opioid Intoxication) : Flushing, Pinpoint pupils, Drowsiness, Dry mouth, Slurred speech, Impaired cognition
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