History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include history of mental illness, history of other substance abuse, male gender, young age, and long-term use of opioids.
maladaptive pattern of opioid use
Overindulgence in procuring opioids and persistent use leading to detrimental physical and mental consequences.
Leads to clinically significant impairment or distress in personal, social, or job-related responsibilities (i.e., failure to fulfil major obligations at work, school, or home) within a 12-month period.
Characterised by recurrent opioid use in hazardous situations, such as driving or operating heavy machines while impaired; opioid-related legal problems; social and interpersonal problems caused by or exacerbated by opioid use; tolerance (marked increase in amount and marked decrease in effect); withdrawal symptoms (after ceasing drug); use of substance in larger amounts and for longer periods than intended; persistent desire or repeated unsuccessful attempts to quit; much time/activity expended to obtain and use substance and recover from its effects; reducing or ceasing important social, occupational, or recreational activities; or continued use despite knowledge of adverse consequences.
high Addiction Severity Index (ASI) score
Designed to assess the patient's problem severity in seven areas of functioning: medical status, employment/support status, drug use, alcohol use, legal status, family/social relationships, and psychiatric status.
A higher score on the ASI reflects a higher severity of opioid use disorder. Addiction Severity Index Opens in new window
blunting of pleasurable opioid effects
Characteristic of tolerance seen in opioid use disorder.
Individual may seek to increase consumption of drug to obtain similar drug-reinforcing effects.
miosis
Seen in opioid intoxication as well as opioid use disorder.
Pinpoint pupils seen in overdose.
Miosis may be absent if intoxication is due to synthetic opioids such as fentanyl.[2]
dilated pupils
Characteristic of withdrawal seen in opioid use disorder.
shallow/slow respirations or apnoea
Seen in opioid intoxication or overdose (<10 breaths per minute).
needle marks, scars, or necrosis on skin near veins
Seen in opioid use disorder.
unconsciousness
Seen in opioid overdose.
pulse <40 bpm
Seen in opioid overdose.
Other diagnostic factors
common
chronic constipation
Adverse effect of opioid use.
Seen in opioid use disorder.
weight loss
Seen in opioid use disorder.
nausea/vomiting
Characteristic of tolerance or withdrawal seen in opioid use disorder.
Seen as early as 2 to 3 days following continuous use of opioids.
sedation
Characteristic of tolerance seen in opioid use disorder.
Seen as early as 2 to 3 days following continuous use of opioids.
restless sleep/insomnia
Characteristic of withdrawal seen in opioid use disorder.
memory impairment
Seen in opioid intoxication.
sneezing
Characteristic of withdrawal seen in opioid use disorder.
yawning
Characteristic of withdrawal seen in opioid use disorder.
abdominal cramps
Characteristic of withdrawal seen in opioid use disorder.
diarrhoea
Characteristic of withdrawal seen in opioid use disorder.
backache/muscle spasms
Characteristic of withdrawal seen in opioid use disorder.
hot and cold flashes
Characteristic of withdrawal seen in opioid use disorder.
hypotension
Seen in opioid intoxication.
sedation
Seen in opioid intoxication as well as opioid use disorder.
confusion
Seen in opioid intoxication.
slurred speech
Seen in opioid intoxication.
aggressive behaviour
Characteristic of withdrawal seen in opioid use disorder.
excess perspiration or lacrimation
Characteristic of withdrawal seen in opioid use disorder.
rhinorrhoea
Characteristic of withdrawal seen in opioid use disorder.
restlessness
Characteristic of withdrawal seen in opioid use disorder.
piloerection
Characteristic of withdrawal seen in opioid use disorder.
tachypnoea
Characteristic of withdrawal seen in opioid use disorder.
hypertension
Characteristic of withdrawal seen in opioid use disorder.
uncommon
arrhythmias
Characteristic of withdrawal seen in opioid use disorder.
seizures
Neonates of opioid-dependent mothers may present with seizures during withdrawal.
Risk factors
strong
young age
Consistently associated with greater risk for opioid use disorder.[27] In the US in 2020, opioid misuse was highest among those aged 18 to 25 years compared with other age groups.[28]
A 20-year study enrolling over 1000 children and adolescents in North Carolina found that by the age of 30 years, 1 in 4 had used non-heroin opioids.[29] The most robust risk markers for opioid use were tobacco use, cannabis use, and depression.[29]
Younger age is also associated with greater likelihood of initiating injection drug use among individuals on prescription opioids.[30]
history of a mental health disorder
Comorbid psychiatric disorders such as bipolar disorder, ADHD, major depression, anxiety disorders, personality disorders, PTSD, and psychosis are associated with increased risk of substance abuse, including opioid use.[17][18][19][20][21] People with mental health disorders are also more likely to receive prescription opioids than those without mental health disorders, and to initiate injection drug use.[30][31]
Possible reasons for the association include substance use causing psychiatric disorders, people with psychiatric disorders using substances to treat symptoms, and shared risk factors for both conditions.[22]
history of substance use
long-term opioid therapy
childhood trauma
Adverse childhood experiences, including household dysfunction and emotional and sexual abuse, increase the likelihood of non-medical opioid use and misuse of prescription opioids.[33][34][35]
Evidence suggests a dose-response relationship, with increasing numbers of childhood traumas increasing the risk of opioid use disorder.[34][35]
weak
family history of substance use
One study found parental medical prescription opioid use to be associated with a 28% increased likelihood of adolescent medical use of prescription opioids, and with a 53% increased risk for adolescent misuse.[36]
Genetic influences contribute to about 50% of the risk of drug addiction, and it is very likely that multiple genes are involved. Heritability estimates range from 23% to 54% for opioid use disorder.[23] Variants in genes including those encoding the mu opioid receptor, the delta opioid receptor, the dopamine D2 receptor, and brain-derived neurotrophic factor have been associated with small but reproducible effects on risk of opioid use disorder.[23]
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