Condition

Opioid Use Disorder

Editors: William Becker MD; Sergio Zaderenko MD; Esther Jolanda van Zuuren MD; Alexander Rae-Grant MD, FRCPC, FAAN

American College of PhysiciansProduced in collaboration with American College of Physicians
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Background Information

Description

  • Opioid use disorder is characterized by cognitive, behavioral, and physiological symptoms that indicate a continued problematic pattern of opioid use leading to clinically significant impairment or distress.
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Also Called

  • OUD
  • Opiate use disorder
  • Opiate/opioid abuse
  • Opiate/opioid addiction
  • Opiate/opioid dependence
  • Opiate/opioid misuse
  • Narcotic abuse
  • Narcotic addiction
  • Narcotic dependence
  • Narcotic misuse

Definitions

  • Opioid misuse is the use of opioid medications in a manner other than as directed by a prescriber or the use of any opioid in a manner, situation, amount, or frequency that can cause harm to self or others.
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  • Psychological dependence describes a subjective need for a substance to experience its positive effects or avoid negative effects associated from its absence.
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  • Physical dependence describes a state of neuroadaptation in which drug-specific withdrawal symptoms can result from abrupt cessation, rapid dose reduction, antagonist administration, or decreased blood levels of the drug.
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  • Opioid withdrawal syndrome describes symptoms resulting from the reduction or cessation of opioid use or the administration of an opioid antagonist after the induction of physiological tolerance.
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  • Precipitated withdrawal occurs with the displacement of opioid agonist from opioid receptors by an opioid antagonist or partial opioid agonist in a patient with opioid dependence, leading to opioid withdrawal.
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  • Opioid overdose is a toxic reaction or death resulting from inadvertent or deliberate intake of dose much larger than normally used for treating an illness or habitually used by the patient.
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  • Opioid intoxication is a condition following opioid intake resulting in changes of consciousness, cognition, perception, judgment, affect, behavior, or other psychophysiological functions.
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    • Intoxication resolves in time if no tissue damage or other complications.
    • Intoxication is influenced by the opioid type and dose and individual's level of tolerance.
  • Various terms refer to opioid substances.
    • Opiates are alkaloids derived from opium poppy plants (Papaver somniferum).
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      • Opiates produce analgesia, euphoria, stupor, coma, and respiratory depression.
      • The term opiate does not include synthetic opioids.
    • Opioids are psychoactive chemical with similar pharmacological effects as morphine by binding to opioid receptors. The term opioid includes opiates, endogenous substances, and synthetic/semisynthetic agents.
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    • Narcotic drugs may refer specifically to opioids, but may also refer to a wide variety of substance that contains opium, opiates, derivatives of opium and opiates, poppy straw and concentrate of poppy straw, coca leaves, cocaine, its salts, optical and geometric isomers, and salts of isomers, and ecgonine, its derivatives, their salts, isomers, and salts of isomers (
      1
      , Drug Enforcement Administration Resource Guide 2017 PDF).
      table iconTable 1. Street Names of Common Opioids
      Table 1: Street Names of Common Opioids
      Opioid Street Name
      Heroin Brown sugar, chiva dope, H, horse, junk, skag, skunk, smack, white horse
      Codeine Captain Cody, coties, lean, schoolboy, sizzurp, purple drank, doors & fours, loads, pancakes and syrup
      Fentanyl (Actiq, Duragesic, Sublimaze) Blonde, blue diamond, snowflake, humid, jackpot, murder 8, tango and cash, TNT, birria (with heroin)
      Hydrocodone and dihydrocodeinone (Vicodin, Lortab, Lorcet) Vike, veeks, idiot pills, scratch, 357s, lemonade, bananas, dones, droco, lorries
      Hydromorphone (Dilaudid) D, dillies, K2, needle candy
      Meperidine (Demerol) Demmies, pain killer
      Methadone (Dolophine, Methadose) Amidone, biscuits, fizzies, jungle juice, Maria, wafer, chocolate chip cookies (with MDMA)
      Morphine (Duramorph, Roxanal) Dreamer, first line, joy juice, morpho, Miss Emma, monkey, white stuff, Mister Blue, unkie
      Oxycodone (OxyContin, Percodan, Percocet) 30s, 40s, 512s, Oxy, beans, blues, buttons, cotton, kickers, killers, percs, roxy
      Oxymorphone (Opana) Biscuits, blue heaven, blues, Mrs. O, o bomb, octagons, stop signs

      Abbreviations: MDMA, 3,4-methylenedioxy-methamphetamine.

      Reference - National Institute on Drug Abuse Commonly Abused Drugs Chart 2020 Aug or in Spanish.

Epidemiology

Incidence/Prevalence

    Evidence Synopsis

    The estimated prevalence of opioid use disorder among persons ≥ 12 years old in the United States was 0.6% in 2019, with higher rates reported in patients treated with opioids for chronic noncancer pain. The prevalence of any opioid prescription in a given year between 2007 and 2016 in the United States ranged from 14% to 51%.
    • STUDY SUMMARY
      estimated prevalence of opioid use disorder (OUD) 0.6% among persons ≥ 12 years old in United States in 2019; opioid misuse reported in 3.7%
      CROSS-SECTIONAL STUDY: SAMHSA 2020; HHS Publication No. PEP20-07-01-001

    • STUDY SUMMARY
      prevalence of any prescription opioid use in United States appears to range from 14% among commercial beneficiaries to 51% among Medicare Advantage beneficiaries < 65 years old with disabilities
      COHORT STUDY: BMJ 2018 Aug 1;362:k2833

    • STUDY SUMMARY
      median prevalence of opioid use disorder reported to be 4.5% in patients treated with opioids for chronic noncancer pain
      RANDOMIZED TRIAL: Addiction 2013 Apr;108(4):688

    • STUDY SUMMARY
      opioid use disorder reported in 41.3% of adults with ≥ 5 opioid prescriptions within 1 year for noncancer pain in United States
      CROSS-SECTIONAL STUDY: Subst Abuse Rehabil 2015;6:83

Risk Factors

  • The risk of developing opioid use disorder increases with repeated opioid use, with higher opioid doses, or when opioids are injected.
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  • Genetic heritability is estimated to contribute about 50% of the susceptibility to any substance use disorder, including opioid use disorder (Lancet 2019 Apr 27;393(10182):1760).
  • Other risk factors for substance use include any of the following:
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    • Substance misuse by family and peers, and favorable view of substance use by community or family
    • Younger age when starting substance use
    • Persistent emotional distress or aggressiveness that starts early
    • Psychiatric disorder
    • Family conflict, abuse, or neglect
    • Poor academic performance or interest in school
    • Low socioeconomic status
    • High availability of substance
  • STUDY SUMMARY
    younger age, male sex, psychiatric disorder, and current or prior substance use disorder each associated with increased risk of opioid misuse in outpatients with opioid prescriptions
    SYSTEMATIC REVIEW: Ann Emerg Med 2019 Nov;74(5):634

  • STUDY SUMMARY
    long-term use of prescription opioids dispensed for noncancer pain associated with increased risk of initiating injection drug use in persons aged 11-65 years without history of substance use
    COHORT STUDY: BMJ 2021 Nov 18;375:e066965

  • STUDY SUMMARY
    each refill and each additional week of opioid prescription associated with increased rate of opioid misuse in postsurgical patients
    COHORT STUDY: BMJ 2018 Jan 17;360:j5790

  • STUDY SUMMARY
    history of substance use disorder, psychiatric comorbidities, and pain disorders among factors associated with increased risk and severity of opioid use disorder in adults who were prescribed opioids in United States
    CROSS-SECTIONAL STUDY: Subst Abuse Rehabil 2015;6:83

  • STUDY SUMMARY
    long-term episodes of opioid use in United States appears to be high among Medicare beneficiaries < 65 years old with disabilities
    COHORT STUDY: BMJ 2018 Aug 1;362:k2833

Associated Conditions

Substance Use
  • Opioid use is often associated with other substance use and substance use disorders, such as alcohol use disorder, sedative, hypnotic, and anxiolytic use disorder, cannabis use disorder, and/or tobacco use.
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    ,
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  • FDA public health advisory regarding use of kratom, a naturally growing plant in Thailand, Malaysia, Indonesia, and Papua New Guinea, which is gaining popularity in the United States for a wide range of uses, including management of opioid withdrawal.
    • Currently, there are no FDA-approved therapeutic uses for kratom, and it is reported to be associated with similar risks of abuse, addiction, and in some cases, death as opioids.
    • The FDA is aware of use of kratom to treat conditions like pain, anxiety, and depression as an alternative or adjunct to opioids, as well as recreational use for euphoric effects or to treat opioid withdrawal.
      • There is no reliable evidence to support the use of kratom as a treatment for opioid use disorder or opioid withdrawal.
      • 36 deaths have been reported to be associated with the use of kratom-containing products.
      • There have been some reports of kratom being laced with other opioids, such as hydrocodone.
    • Kratom use is associated with serious side effects, including seizures, liver damage, and withdrawal symptoms.
    • The FDA has exercised jurisdiction over kratom as an unapproved drug and has also taken action against kratom-containing dietary supplements.
    • Reference - FDA Statement 2017 Nov 14
  • Drugs Psychiatric_Disorders Substance_Use_and_PoisoningFDA warning of illegal marketing, and possible abuse, of products containing tianeptine (FDA Press Release 2018 Nov 20)02/10/2019 06:28:00 PMFDA has issued a warning of illegal marketing and possible abuse of products containing tianeptine, in which companies market products containing tianeptine as dietary supplements, with unauthorized claims to treat conditions including opioid use disorder, pain, and anxiety.
    • Tianeptine misuse is reported to produce clinical effects mimicking those of opioid toxicity and withdrawal.
    • Tianeptine is approved to treat depression in other countries but is not approved in the United States.
    • Reference - FDA Press Release 2018 Nov 20
Other Associated Conditions

Etiology and Pathogenesis

  • Opioid drugs are agonists of mu-opioid receptors (MORs).
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    • Opioids mediate feelings of "reward" and analgesia via MORs in areas of the brain that process pain and emotion.
    • Opioids affect breathing via MORs in the brainstem. MOR agonists inhibit neuronal activity and thus may cause respiratory depression.
  • Different opioid agonists and antagonists have differential effects via their respective affinities to MORs, their functional effects (agonist, partial agonist, or antagonist), and their selectivity for MORs compared to other receptors.
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  • Addiction in general involves learning on a physiological level, particularly within brain areas associated with reward.
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    • Repeated opioid use, followed by feelings of reward and analgesia, strengthens the association between behavior and stimuli that precede opioid use and subsequent feelings.
    • These associations also may disrupt striatocortical pathways that mediate prefrontal functioning and thus impair self-regulation.
    • Changes from the repeated effects of opioid intoxication, withdrawal, and craving to the dopaminergic circuits of the basal ganglia, extended amygdala, and prefrontal cortex persist after opioid use is discontinued.
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1Level 1 (likely reliable) Evidence
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2Level 2 (mid-level) Evidence
Representing research results addressing clinical outcomes, and using some method of scientific investigation, but not meeting the quality criteria to achieve Level 1 evidence labeling.
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