1. Assessing Opioid Use Disorder, part 1
DATE: December 6, 2016
PRESENTED BY: Melissa Weimer, DO, Assistant Professor of Medicine

2. Objectives Identify key features of opioid use disorder.
Understand that differentiating opioid use disorder from pain is a complex task. 2

3. Spectrum of Opioid Use Disorder
Self medication (chemical coping)
Mood
Sleep
Traumatic memories
Prevent withdrawal
Reward (to get high)
Opioid Use disorder
Diversion for profit
Medication or substance misuse by persons with pain may occur for diverse reasons. Helps to identify and address the driver of misuse. Misuse may be self-limited or may be a sign of opioid use disorder in vulnerable people.

4. Continuum of Problematic Opioid Use
Mild indiscretion
Repeated misuse
Severe Opioid Use Disorder (i.e. addiction)
Opioid use disorder
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5. Opioid Related Side Effects vs. Opioid Use Disorder
Physical Dependence
Tolerance
Physiologic adaptations
to chronic opioid therapy (occur in all patients who take opioids > 2 weeks)
Family members often misunderstand the effects of opioids and what is physical dependence, tolerance, and addiction or even withdrawal. It’s really important when we have patients on opioids to educate the family that addiction is different from the normal, neuroadaptive processes; it’s a maladaptive behavior that we see sometimes associated with opioid misuse.
Opioid Use Disorder
Maladaptive behavior associated with opioid misuse
Savage SR, et al. J Pain Symptom Manage Jul;26(1):

6. Copyright © American Psychiatric Association. All rights reserved.
From: DSM-5 Criteria for Substance Use Disorders (SUD): Recommendations and Rationale
Am J Psychiatry. 2013;170(8): doi: /appi.ajp
DSM-5 Criteria: 2-3 = mild SUD, 4-5 = moderate SUD, >6 severe SUD
Date of download:
10/22/2013
Copyright © American Psychiatric Association. All rights reserved.

7. Opioid Use Disorder vs. Chronic Pain Managed with Opioids?
Unable to fulfill role obligations – YES
Social or interpersonal problems due to use – YES
Hazardous use – MAYBE
Tolerance – YES*
Withdrawal/physical dependence – YES*
Taken in larger amounts or over longer period – YES
Unsuccessful efforts to cut down or control – YES
Great deal of time spent to obtain substance – YES
Important activities given up or reduced – YES
Continued use despite harm – YES
Craving – MAYBE
*If opioids are prescribed, this criterion does not apply.

8. Opioid Use Disorder in Clinical Practice
The 4 C’s
Loss of Control
Compulsive use
Continued use despite harms
Craving
Savage SR, et al. J Pain Symptom Manage. 2003;26:

9. Principle Risk Factors for Opioid Use Disorder
Younger age, <45
Previous substance use disorder
Back pain, headache
High dose chronic opioid dose
> 90 mg morphine equivalents/day
Edlund MJ, Martin BC, Devries A, Fan MY, Braden JB, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain Jan;26(1):1-8.

10. What is the Opioid Use Disorder Risk?
Published rates of abuse and/or addiction in chronic pain
populations are 4-26%
Suggests that known risk factors for opioid use disorder in the general population would be good predictors for problematic prescription opioid use
Past cocaine use, h/o alcohol or cannabis use1
Lifetime history of substance use disorder2
Family history of substance use disorder, a history of legal problems3
Heavy tobacco use4
History of severe depression or anxiety4
1. Ives T et al. BMC Health Services Research 2006
2. Reid MC et al JGIM 2002
3. Michna E el al. J Pain and Symptom Management 2004
4. Akbik H et al. J Pain and Symptom Management 2006

11. Conclusions
The DSM-V is the main tool we use to diagnose opioid use disorder
Diagnosing opioid use disorder during pain management is difficult and requires a thorough evaluation (more to come on this)
Risk factors for SUD are generally the same for OUD and prescription OUD

12. Thank You