Opioid use disorder

Last updated: January 13, 2023

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Opioid use disorder (OUD) is a chronic disease characterized by physical and psychological dependence on prescription and/or illicit opioids. The prevalence of OUD in the United States has risen sharply in recent decades. Core clinical features of OUD are a persistent pattern of maladaptive behaviors related to the pursuit and use of opioids, including use despite adverse consequences and a preoccupation with obtaining opioids. Diagnosis is based on DSM-5 criteria. Medication-assisted treatment is the cornerstone of management, combining medications for opioid use disorder (MOUD) with individualized psychosocial treatment. Long-acting opioid agonists (i.e., methadone or buprenorphine) are most commonly used and have comparable long-term outcomes for addressing cravings and opioid withdrawal syndrome (OWS) and reducing the risk of overdose. Naltrexone may be appropriate for patients trying to abstain from opioid use. OUD is a highly stigmatized lifelong condition that requires a strong therapeutic alliance and patient-centered approach to address relapses, comorbid conditions (e.g., PTSD, infectious complications of injecting drugs), and other circumstances that may impact treatment adherence.

Epidemiological data refers to the US, unless otherwise specified.

Opioid agonists bind at κ-, δ-, and μ-opioid receptors throughout the body. Clinical features of OUD (e.g., physical dependence and compulsive use) result from repeated stimulation of μ-opioid receptors in the brain.

Acute use [3][4]

Long-term use [3][4]

Long-term opioid use leads to upregulation of the cAMP pathway (to offset inhibition resulting from opioids), resulting in:

Opioid cessation [3]

See “Management of substance use disorder” for screening recommendations. Utilize DSM-5 criteria based on clinical suspicion for OUD or for patients who screen positive for unhealthy drug use.

DSM-5 diagnostic criteria for opioid use disorder [6]

  • Taking larger amounts of opioids and for longer than intended
  • Inability to reduce opioid intake despite a desire to do so
  • Spending excessive time obtaining, using, or recovering from opioids
  • Craving or having a strong desire to use opioids
  • Failing to fulfill family, work, or school obligations as a result of opioid use
  • Continued use of opioids despite negative social or interpersonal consequences
  • Stopping or limiting important social, work, or leisure activities as a result of opioid use
  • Repeated opioid use in physically hazardous situations
  • Continued opioid use despite knowledge of its personal harm (physical and/or psychological)
  • One or both of the following manifestations of tolerance:
    • Increasingly larger amounts of opioids are needed to achieve the desired effect.
    • Effects are increasingly diminished with the use of the same amount of opioids.
  • One or both of the following manifestations of withdrawal:


  • OUD: ≥ 2 criteria occurring within a 12-month period
  • Exceptions: Physical dependence (i.e., the presence of tolerance and/or withdrawal) is not considered a criterion in patients solely using opioids under appropriate medical supervision.
  • Severity
    • Mild: 2–3 criteria
    • Moderate: 4–5 criteria
    • Severe: 6–7 criteria

The presence of tolerance and/or withdrawal alone is not sufficient to diagnose OUD in patients solely using opioids as prescribed under appropriate medical supervision. [6]

The differential diagnoses listed here are not exhaustive.

Approach [7]

OUD is a chronic disorder. Treatment aims to prevent relapse of unhealthy drug use. [5]

Do not withhold MOUD from patients who decline a psychosocial evaluation or if comprehensive addiction treatment is unavailable. [7]

Medication for opioid use disorder (MOUD) [5]

MOUD involves the treatment of OUD with a long-acting opioid agonist (i.e., methadone or buprenorphine) or antagonist (i.e., naltrexone). See “Management of opioid withdrawal” for details on initiating treatment for OWS.

  • Higher success rates than abstinence-based treatment
  • Initiate under medical supervision
  • Continue for as long as the patient benefits from treatment.

Opioid agonist therapy

Methadone and buprenorphine have comparable long-term efficacy and safety outcomes. [5]

Opioid antagonist therapy

To avoid precipitated withdrawal, ensure opioid abstinence for 7–14 days prior to starting naltrexone. [7]

We list the most important complications. The selection is not exhaustive.

Provide take-home naloxone kits to all patients with OUD and/or risk factors for opioid overdose. Train patients and close contacts in the use of naloxone for treating opioid overdose. [7]

  1. Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 2016; 375 (4): p.357-368. doi: 10.1056/nejmra1604339 . | Open in Read by QxMD
  2. Kosten TR, Baxter LE. Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. The American Journal on Addictions. 2019; 28 (2): p.55-62. doi: 10.1111/ajad.12862 . | Open in Read by QxMD
  3. Srivastava AB, Mariani JJ, Levin FR. New directions in the treatment of opioid withdrawal. Lancet. 2020; 395 (10241): p.1938-1948. doi: 10.1016/s0140-6736(20)30852-7 . | Open in Read by QxMD
  4. Crotty K, Freedman KI, Kampman KM. Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. J Addict Med. 2020; 14 (2): p.99-112. doi: 10.1097/adm.0000000000000635 . | Open in Read by QxMD
  5. Ashford RD, Brown AM, McDaniel J, Curtis B. Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals. Subst Use Misuse. 2019; 54 (8): p.1376-1384. doi: 10.1080/10826084.2019.1581221 . | Open in Read by QxMD
  6. Miller SC, Fiellin DA, Rosenthal RN, Saitz R. The ASAM Principles of Addiction Medicine. LWW ; 2018
  7. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  8. Taylor JL, Samet JH. Opioid Use Disorder. Ann Intern Med. 2022; 175 (1): p.ITC1-ITC16. doi: 10.7326/aitc202201180 . | Open in Read by QxMD
  9. Webster, Lynn R. Risk Factors for Opioid-Use Disorder and Overdose. Anesthesia & Analgesia. 2017; 125 (5): p.1741-1748. doi: 10.1213/ane.0000000000002496 . | Open in Read by QxMD
  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association ; 2013

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