Opioid Use Disorder __________________________________________________________________________
tion that can manifest as tolerance and withdrawal symptoms reflecting uninterrupted exposure to the opioid independent of addiction). This terminology is largely abandoned as imprecise and obsolete. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) defines opioid use disorder as a problematic pattern of opioid use, leading to clinically signifi- cant impairment or distress. The diagnosis of OUD is made by meeting two or more criteria in a one-year period [2; 7]: • Opioids taken in larger amounts or over a longer period than was intended • A persistent desire or unsuccessful efforts to cut down or control use • Excessive time spent to obtain, use, or recover from using the opioid • Craving, an intense urge to use • Opioid use interferes with obligations • Continued use despite life disruption • Reduction or elimination of important activities due to use • Recurrent use in physically hazardous situations • Continued use despite physical or psychologic problems • Tolerance − Need for increased doses of the opioid for the desired effect − A markedly diminished effect with continued use of the same amount • Withdrawal Note: The criteria for tolerance and withdrawal are not consid- ered to be met for those taking opioids solely under appropriate medical supervision. In summary, the term dependence is used to describe two separate phenomena. Pharmacologically, drug dependence is characterized by the presence of tolerance and a withdrawal syndrome. Psychiatrically, drug dependence is characterized by compulsive use, inability to reduce use, preoccupation, drug-seeking behaviors, and a heightened vulnerability to relapse after abstinence [8]. Despite replacement of “opioid dependence” with opioid use disorder in the DSM-5-TR, use of this term persists, along with conflation of tolerance with opioid addiction and exposure to medically indicated opioid analgesics with opioid dependence with opioid addiction. Pseudoaddiction describes drug-seeking behaviors iatrogeni- cally produced in pain patients by inadequate pain treatment. This is manifested as preoccupation with and pursuit of opioid medication driven by a desire for pain relief, not the drug’s mood-altering effects. Pseudoaddiction develops in three phases. Initially, the patient receives an inadequate level of analgesia, which leads to the patient’s escalation of analgesic demands and behavioral changes. This may be exaggerated to convince others of the pain severity and need for more medica-
INTRODUCTION The purpose of this course is to provide the reader with a current, evidence-based overview of opioid use disorder and its treatment. Topics covered in this review include the history and demographics of illicit and prescription opioid abuse; risk factors, background characteristics, and comorbid conditions of opioid abusers; the pharmacology of opioid drugs; the biologic and behavioral characteristics of opioid dependence; and management of opioid dependence, including treatment of overdose, detoxification and withdrawal, agonist replace- ment therapy, and drug-free approaches. Additional areas of the course will be devoted to the abuse liability of prescription opioids and the impact of opioids on the fetus. DEFINITIONS The definitions and terminology used to describe opioids, addiction, and pain vary in meaning to different stakeholders, and while periodically revised, previous iterations circulate. Some terminology perpetuates misinformation or myths. A few widely used updated definitions include [1; 2; 3; 4; 5; 6]: • Misuse, nonmedical use : Any use of a drug prescribed to someone else or of one’s own prescription departing from the authorized directions. • Abuse : This term from older DSMs has been largely replaced by misuse. Definition varies widely depending on the context, but generally means a maladaptive pat- tern of use with the primary intent of achieving eupho- ria or getting high. The Drug Enforcement Agency (DEA) defines abuse as the use of a schedule II through V drug in a manner or amount inconsistent with the medical or social pattern of a culture. The American Psychiatric Association defines abuse as “a maladaptive pattern of substance use, leading to clinically significant impairment or distress as manifested by one or more behaviorally based criteria.” • Addiction : Defined by the American Society of Addiction Medicine (ASAM) as “a primary chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing the development and manifestations.” It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Addiction has been referred to as psychologic dependence, but this terminology is incor- rect as persons with addiction have become psychologi- cally dependent on the substance, but not all persons with psychologic dependence develop addiction. • Dependence : Introduced by the APA to replace the term “addiction,” opioid dependence described both psychologic dependence (a symptom of addiction) and physical dependence (a process of neurobiologic adapta-
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MDRI2026
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