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Opioid use disorder

Definition
OUD is defined as a pattern of recurring opioid use leading to clinically significant impairment or distress.
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Pathophysiology
The positive reinforcing effects of opioid use are mediated by indirect downstream activation of dopamine receptors. Repeated use ultimately leads to physiological dependence with tolerance, and withdrawal if use is ceased.
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Epidemiology
In the US, the rates of past-year non-medical opioid use, heroin use, and heroin abuse are estimated at 4,240, 260, and 190 per 100,000 persons, respectively.
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Disease course
The development of opioid dependence mirrors other drug dependencies. Possible warning signs may include changes in peer group, decreasing involvement in social/leisure activities, isolation from family/old friends, mood changes, and increased frequency of negative behaviors, including criminal acts. Development of tolerance leads to consumption of escalating opioid doses, which increases the risk of respiratory depression and death.
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Prognosis and risk of recurrence
OUD is associated with an increase in mortality, with an estimated standardized mortality ratio of 14.66 (95% CI, 12.82-16.50) In the US, out of 100 daily deaths due to drug overdose, nearly 50 deaths are due to prescription opioids, and 20 are due to heroin overdose.
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Key sources
The following summarized guidelines for the evaluation and management of opioid use disorder are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023), the American Heart Association (AHA 2023), the United States Department of Defense (DoD/VA 2021), the American Society of Addiction Medicine (ASAM 2020), the Canadian Association of Emergency Physicians (CAEP 2020), the U.S. Preventive Services Task Force (USPSTF 2020), the College of Family Physicians of Canada (CFPC 2019), the Canadian Research Initiative in Substance Misuse (CRISM 2019), the American Gastroenterological Association (AGA 2019), the Canadian Institutes of Health Research (CIHR 2018), the European Society of Medical Oncology (ESMO 2018), and the Vancouver Coastal Health (VCH 2016).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per VA 2021 guidelines, insufficient evidence to recommend for or against screening for OUDs in primary care to facilitate enrollment in treatment.
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  • Indications for screening (PEER)

  • Diagnosis

2.Diagnostic investigations

Initial clinical assessment: obtain a comprehensive assessment for treatment planning. Do not delay or preclude pharmacotherapy for OUD because of the completion of all assessments. Complete assessments soon after initiating pharmacotherapy, if not completed before that.
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  • Initial laboratory testing

  • Urine drug testing

  • Urine drug testing (PEER)

  • Screening for comorbidities

3.Medical management

General principles: ensure that all approved medications for the treatment of OUD are available to all patients. Take into consideration the patient's preferences, past treatment history, the current state of illness, and treatment setting when deciding between the use of methadone, buprenorphine, and naltrexone.
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  • Setting of care (primary care)

  • Setting of care (emergency department)

  • Setting of care (residential care)

  • Withdrawal management

  • Withdrawal management (PEER)

  • Buprenorphine/naloxone

  • Buprenorphine/naloxone (PEER)

  • Methadone

  • Methadone (PEER)

  • Slow-release oral morphine

  • Injectable opioid agonists

  • Naltrexone

  • Naltrexone (PEER)

  • Alpha-adrenergic agonists

  • Cannabinoids

4.Nonpharmacologic interventions

Psychosocial therapy
As per VA 2021 guidelines:
Insufficient evidence to recommend for or against any specific psychosocial interventions in addition to addiction-focused medical management in patients receiving medication treatment for OUD.
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Insufficient evidence to recommend for or against any specific psychosocial interventions in patients with OUD if OUD pharmacotherapy is contraindicated, unacceptable or unavailable.
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  • Psychosocial therapy (PEER)

  • Mutual help programs

  • Mindfulness-based therapies

  • Technology-based interventions

5.Specific circumstances

Female patients: ask females about their use of opioids when they present for pain management. Obtain screening and offer brief intervention and referral to treatment.
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  • Pregnant patients

  • Patients with other substance use disorders

  • Patients with opioid-induced constipation

  • Patients with opioid overdose

6.Patient education

General counseling: as per CAEP 2020 guidelines, offer overdose education during the emergency department visit in all patients at risk of opioid overdose and persons likely to witness an opioid overdose in the future, such as friends, partners, and family members of patients using opioids.
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7.Preventative measures

Safe opioid prescribing
Establish opioid prescribing policies in emergency departments aligning local practices by providing guidance on screening, risk assessment, opioid selection, and judicious course duration to reduce the risk of subsequent OUD.
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Counsel patients on the risks of adverse events, overdose, and dependence and provide instructions for safer storage and disposal when prescribing opioids in the emergency department.
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