Opioid Use Disorder (OUD)

According to the American Psychiatry Association (APA) opioid use disorder (OUD) is a chronic disorder, with serious potential consequences including disability, relapses and death. Opioids are known to produce a feeling of euphoria which increase the odds that people will continue using them despite negative consequences. 

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5-TR) describes opioid use disorder as a problematic pattern of opioid use with at least two of the following occurring within a 12-month period: 

1. Taking larger amounts or taking drugs over a longer period than intended.
2. Persistent desire or unsuccessful efforts to cut down or control opioid use.
3. Spending a great deal of time obtaining or using the opioid or recovering from its effects.
4. Craving, or a strong desire or urge to use opioids
5. Problems fulfilling obligations at work, school or home.
6. Continued opioid use despite having recurring social or interpersonal problems.
7. Giving up or reducing activities because of opioid use.
8. Using opioids in physically hazardous situations such as driving while under the influence of opiates.
9. Continued opioid use despite ongoing physical or psychological problem likely to have been caused or worsened by opioids.
10. Tolerance (i.e., need for increased amounts or diminished effect with continued use of the same amount)
11. Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.

With frequent use, abruptly stopping use of opioids leads to withdrawal symptoms, including generalized pain, chills, cramps, diarrhea, dilated pupils, restlessness, anxiety, nausea, vomiting, insomnia, and very intense cravings. However, according to the APA, people do not die from opioid withdrawal. Because these symptoms are severe it creates significant motivation to continue using opioids to prevent withdrawal. 

While opioid use disorder is similar to substance use disorder, it has many unique features that aren't found with the abuse of drugs like cocaine or marijuana. Opioids can lead to physical dependence within a short time. The "7 Days: Opioid Crisis in Arkansas" reports that seven consecutive days of prescription opioid pain killer use is enough to cause tolerance and dependence. In other words, the body will become used to opioids that it has difficulty functioning without opioids. 

According to the American Medical Association (AMA), an estimated 3% to 19% of people who take prescription pain medications develop an addiction to them.  People misusing opioids may try to switch from prescription pain killers to heroin when it is more easily available. About 45% of people who use heroin started with an addiction to prescription opioids, according to the AMA. 

Effective treatments are available; however, only about one in four people with opioid use disorder receive specialty treatment. Considered the “gold-standard” of treatment, medications for opioid use disorder (MOUD), are an evidence-based treatment for individuals with an opioid use disorder. Counseling and behavioral therapies may be an important part of treatment alongside medications; however, they are effective by themselves. Medications are also used to relieve cravings, relieve withdrawal symptoms and block the euphoric effects of opioids. These medications do not “cure” the disorder, but rather improve safety and prevent withdrawal symptoms which can lead to relapse or continued drug use.

Three U.S. Food and Drug Administration (FDA)-approved medications are commonly used to treat opioid use disorder:

• Methadone – Prevents withdrawal symptoms and reduces cravings in people with OUD. It does not cause a euphoric feeling once patients become tolerant to its effects. It is available only in specially regulated clinics.
• Buprenorphine (Subutex)– Partially blocks the effects of other opioids, displaces current opioids in the body, and reduces or eliminates withdrawal symptoms and cravings. Buprenorphine treatment (detoxification or maintenance) is provided by specially trained and qualified clinicians who have received a waiver from the DEA).
  • Buprenorphine-Naloxone (Suboxone) - As stated above, buprenorphine partially blocks the effects of opioids. Suboxone combines buprenorphine with naloxone (see below) to prevent accidental or intentional use to get high.
  • Buprenorphine extended-release (Sublocade) – a once-a-month injection of buprenorphine that is available to individuals that have shown tolerance to oral buprenorphine.
• Naltrexone – Blocks the effects of other opioids preventing the feeling of euphoria. It is available from office-based providers in pill form or monthly injection.

The National Institute on Drug Abuse (NIDA) emphasizes that these medications do not substitute one addiction for another. The dosage of medication used in treatment does not cause euphoria (a high)—it helps reduce opioid cravings and withdrawal. It helps restore balance to the brain circuits affected by addiction.

Treatment typically involves cognitive behavioral approaches, such as encouraging motivation to change and education about treatment and relapse prevention. It often includes participation in mutual-aid organizations, such as Narcotics Anonymous. MOUD have been shown to help people stay in treatment, and to reduce opioid use, opioid overdoses and risks associated with opioid use disorder, including HIV and HCV. 

Different levels of treatment may be needed by different individuals or at different times, including outpatient counseling, intensive outpatient treatment, inpatient treatment, or long-term therapeutic communities. Opioid use disorder often requires continuing care to be effective. Evidence-based care for opioid use disorder involves several components, including:

• Personalized diagnosis and treatment planning tailored to the individual and family.
• Long-term management – Addiction is a chronic condition with the potential for both recovery and recurrence. Long-term outpatient care and support is important.
• Access to FDA-approved medications.
• Effective behavioral interventions delivered by trained professionals.
• Coordinated care for addiction and other conditions.
• Recovery support services, such as mutual aid groups, peer support specialists, and community services.

Naloxone (brand name Narcan) is a life-saving medication used to quickly reverse an opioid overdose. It can reverse and block the effects of opioids and return normal breathing to someone whose breathing has slowed or stopped because of an opioid overdose. It is available as a prefilled auto-injection device, as a nasal spray and as an injectable. Naloxone is safe and has no effects if administered to someone not experiencing an opioid overdose.

Naloxone administration will lead to rapid withdrawal from opioids. While it will improve breathing that has been slowed due to opioids, naloxone may also lead to vomiting which may increase the risk of choking. When administering naloxone, it is important to make sure the person being saved does not choke. Another important reminder is that naloxone works for a short amount of time. Therefore, a person may need multiple doses. If someone has been given naloxone due to a suspected overdose, they should be taken to the hospital after being given naloxone due to the risk of re-intoxication.

In April 2018, U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., released a public health advisory to urge more Americans to carry naloxone.