Opiate overuse: a change in diagnostic criteria

In the DSM IV, that is, the Diagnostic and Statistical Manual of Mental Disorders, opioid dependence disorder and opioid addiction disorder are separate. Everyone on a chronic pain medicine for a length of time was expected to be dependent, but not addicted. Addiction was considered rare and was thought to be mostly people who abused opiates. Who took them for pleasure. Oxycontin, heroin, vicodon. Those bad people who were partying. Got what they deserved, didn’t they?

That has changed. My feeling was that it’s been a long time coming, but no one asked me.

In the DSM V, opioid dependence and opioid addiction have been combined into “Opioid Use Disorder”. They are no longer considered separate. They are a spectrum. Anyone who is on chronic opioids is on that spectrum. This is a big change. It has not really penetrated the doctors’ consciousness, much less the patients.

It is quite simple to score. There are 11 criteria. They are yes and no questions. Score and add up. The patients are scored mild, moderate or severe.

Here are the criteria:

Opioid Use Disorder requires meeting 2 or more criteria; increasing severity of use disorder with increasing number of criteria met.

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

2. Recurrent substance use in situations in which it is physically hazardous.

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

4. Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication of desired effect.
(b) markedly diminished effect with continued use of the same amount of the substance.

5. Withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome or
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

6. The substance is often taken in larger amounts or over a longer period of time than intended.

7. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

8. A great deal of time is spent in activities necessary to obtain the substance, use of the substance or recover from its effects.

9. Important social, occupational, or recreational activities are given up or reduced because of substance use.

10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

11. Craving or a strong desire to use opioids.

Mild substance use disorder is yes to 2-3 of these.

My chronic pain patients ask, “Why do you treat me like a drug addict?”

The answer now is, “Because you are on a chronic opiate.”

I am starting to use the criteria in clinic. When I get a new chronic pain patient, I give them the list. I let them tell me.

It is hard because they often recognize 3 or 4 or 5 or more things on the list. They say, “So this is saying I’m addicted.”

“I’m afraid so.”

They grieve.

I am posting this because people are dying. The number of people dying from prescription medicine overdoses taken correctly has outstripped illegal drug use deaths, approximately 27,000 unintentional overdose deaths in 2007.

Here: CDC Grand Grand Rounds: Prescription Drug Overdoses – a U. S. Epidemic.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The CDC article says: “The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids, and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month.”That is “approximately” 14 million people.

Please tell your friends and those you love about this. Thank you.

first published on everything2 on June 4, 2014.