Opioid use disorder
Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids.[12] Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood.[5] Addiction and dependence are important components of opioid use disorder.[13]
Opioid use disorder
Strong desire to use opioids, increased tolerance to opioids, failure to meet obligations, trouble with reducing use, withdrawal syndrome with discontinuation[4][5]
Opioid overdose, hepatitis C, marriage problems, unemployment, poverty[4][5]
Long term[6]
16 million[11]
120,000[11]
Risk factors include a history of opioid misuse, current opioid misuse, young age, socioeconomic status, race, untreated psychiatric disorders, and environments that promote misuse (social, family, professional, etc.).[14][15] Complications may include opioid overdose, suicide, HIV/AIDS, hepatitis C, and problems meeting social or professional responsibilities.[5][4] Diagnosis may be based on criteria by the American Psychiatric Association in the DSM-5.[4]
Opioids include substances such as heroin, morphine, fentanyl, codeine, dihydrocodeine, oxycodone, and hydrocodone.[5][6] A useful standard for the relative strength of different opioids is morphine milligram equivalents (MME).[16] It is recommended for clinicians to refer to daily MMEs when prescribing opioids to decrease the risk of misuse and adverse effects.[17]
Long-term opioid use occurs in about 4% of people following their use for trauma or surgery-related pain.[18] In the United States, most heroin users begin by using prescription opioids that may also be bought illegally.[19][20]
People with an opioid use disorder are often treated with opioid replacement therapy using methadone or buprenorphine.[21] Such treatment reduces the risk of death.[21] Additionally, they may benefit from cognitive behavioral therapy, other forms of support from mental health professionals such as individual or group therapy, twelve-step programs, and other peer support programs.[22] The medication naltrexone may also be useful to prevent relapse.[10][8] Naloxone is useful for treating an opioid overdose and giving those at risk naloxone to take home is beneficial.[23] In 2020, the CDC estimated that nearly 3 million people in the U.S. were living with OUD and more than 65,000 people died by opioid overdose, of whom more than 15,000 were heroin overdoses.[24][25]
Signs and symptoms[edit]
Opioid intoxication[edit]
Signs and symptoms of opioid intoxication include:[5][26]
Cause[edit]
Opioid use disorder can develop as a result of self-medication.[34] Scoring systems have been derived to assess the likelihood of opiate addiction in chronic pain patients.[35] Healthcare practitioners have long been aware that despite the effective use of opioids for managing pain, empirical evidence supporting long-term opioid use is minimal.[36][37][38][39][40] Many studies of patients with chronic pain have failed to show any sustained improvement in their pain or ability to function with long-term opioid use.[37][41][42][43][40]
According to position papers on the treatment of opioid dependence published by the United Nations Office on Drugs and Crime and the World Health Organization, care providers should not treat opioid use disorder as the result of a weak moral character or will but as a medical condition.[15][44][45] Some evidence suggests the possibility that opioid use disorders occur due to genetic or other chemical mechanisms that may be difficult to identify or change, such as dysregulation of brain circuitry involving reward and volition. But the exact mechanisms involved are unclear, leading to debate over the influence of biology and free will.[46][47]
Mechanism[edit]
Addiction[edit]
Addiction is a brain disorder characterized by compulsive drug use despite adverse consequences.[13][48][49][50] Addiction involves the overstimulation of the brain's mesocorticolimbic reward circuit (reward system), essential for motivating behaviors linked to survival and reproductive fitness, like seeking food and sex.[51] This reward system encourages associative learning and goal-directed behavior. In addiction, substances overactivate this circuit, causing compulsive behavior due to changes in brain synapses.[52]
The incentive-sensitization theory differentiates between "wanting" (driven by dopamine in the reward circuit) and "liking" (related to brain pleasure centers).[53] This explains the addictive potential of non-pleasurable substances and the persistence of opioid addiction despite tolerance to their euphoric effects. Addiction surpasses mere avoidance of withdrawal, involving cues and stress that reactivate reward-driven behaviors.[51] This is an important reason detoxification alone is unsuccessful 90% of the time.[54][55][56]
Mitigation[edit]
The "CDC Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022" provides recommendations related to opioid misuse, OUD, and opioid overdoses.[16] It reports a lack of clinical evidence that "abuse-deterrent" opioids (e.g., OxyContin), as labeled by the U.S. Food and Drug Administration, are effective for OUD risk mitigation.[16][94] CDC guidance suggests the prescription of immediate-release opioids instead of opioids that have a long duration (long-acting) or opioids that are released over time (extended release).[16] Other recommendations include prescribing the lowest opioid dose that successfully addresses the pain in opioid-naïve patients and collaborating with patients who already take opioid therapy to maximize the effect of non-opioid analgesics.[16]
While receiving opioid therapy, patients should be periodically evaluated for opioid-related complications and clinicians should review state prescription drug monitoring program systems.[16] The latter should be assessed to reduce the risk of overdoses in patients due to their opioid dose or medication combinations.[16] For patients receiving opioid therapy in whom the risks outweigh the benefits, clinicians and patients should develop a treatment plan to decrease their opioid dose incrementally.[16]
For more specific mitigation strategies regarding opioid overdoses, see opioid overdose § Prevention.
History[edit]
Opiate misuse has been recorded at least since 300 BC. Greek mythology describes Nepenthe (Greek "free from sorrow") and how it was used by the hero of the Odyssey. Opioids have been used in the Near East for centuries. The purification of and isolation of opiates occurred in the early 19th century.[28]
Levacetylmethadol was previously used to treat opioid dependence. In 2003 the drug's manufacturer discontinued production. There are no available generic versions. LAAM produced long-lasting effects, which allowed the person receiving treatment to visit a clinic only three times per week, as opposed to daily as with methadone.[203] In 2001, levacetylmethadol was removed from the European market due to reports of life-threatening ventricular rhythm disorders.[204] In 2003, Roxane Laboratories, Inc. discontinued Orlaam in the U.S.[205]