Opioid Use Disorder DSM-5 Multiple Diagnostic Codes

DSM-5 Category: Substance-Related and Addictive Disorders

Introduction

Opioid Use Disorder has been defined as a problematic pattern of opioid use that results in significant impairment or distress on a clinical level (American Psychiatric Association, 2013). An opioid is any psychoactive chemical that resembles morphine or other opiates in its pharmacological effects. Opioid Use Disorder is a new diagnosis appearing in the DSM-5. The category was created by combining the two disorders of Opioid Dependence and Opioid Abuse from the previous DSM IV. It now incorporates a broad spectrum of illicit and prescribed drugs of the opioid class.

Symptoms of Opioid Use Disorder

According to the DSM-5 Opioid Use Disorder will be diagnosed if two or more of the following symptoms are present and recurring over a 12 month period.

• Opioids are often taken in higher quantities than intended.
• Unable to stop or reduce opiod use.
• Significant time is spent in obtaining, using or recovering from the effects of opiods.
• An intense craving and desire for opiods.
• Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
• Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
• Important social, occupational or recreational activities are given up or reduced because of opioid use.
• Recurrent opioid use in situations in which it is physically hazardous
• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.
• Tolerance, as defined by either of the following:
  • need for markedly increased amounts of opioids to achieve intoxication or desired effect
  • markedly diminished effect with continued use of the same amount of an opioid
• Withdrawal, as manifested by either of the following:
  • the characteristic opioid withdrawal syndrome
  • the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms

The DSM-5 also explains that proper diagnosis depends on the stage at which the individual is in along the continuum of withdrawal – early remission, sustained remission, or maintenance therapy - and if the individual is in an environment where access to opioids is restricted. As well, the diagnosis is mild if there are two or three symptoms, moderate with four or five symptoms and severe with six or more symptoms.

Daily Life

Substance abuse in all forms – nicotine, alcohol or drugs - is the most insidious for individuals to face and overcome. If an individual has a propensity for addiction; it is life-long with no cure. The best one can hope for is to find the personal strength to avoid slipping back into addictive behaviors. It is a matter of beginning each day anew with the realization that substance abuse – or, in this case, opioid abuse – is destructive and the only person that can say ‘no’ is the individual with the disorder.

That does not mean that loved ones and friends cannot play a role in helping the person with Opioid Use Disorder from making good choices. The most important component is a supportive environment free of all substances; and a family that models and encourages healthy living. If there is a member of your family with any type of substance abuse disorder including Opioid Use Disorder – then it is essential that no nicotine, alcohol, prescription medications or even caffeine be left lying around (Wu, Blazer, Li, &Woody, 2011). A substance-free home is an excellent supportive environment.

Persons with substance or opioid use disorder are urged to attend regular counseling sessions; in multiple settings. Family counseling would help uncover any problems among members that could be exacerbating the abuse. It would also help families learn how to help the substance abuser (for more information about forms of psychotherapy refer to the next section). Developing and maintaining a regular schedule that includes counseling will also buoy the abuser in their continued efforts to change their life and find ways to cope with the addictive behavior.

Loved ones should realize that supporting the abuser emotionally is a long-term commitment; and may require an entire upheaval of current family dynamics. Those who are addicted to substances should be led to more rewarding activities such as school, hobbies, physical fitness and gainful employment. Finally, be prepared and sensitive to signs of a return to substance abuse such as that one would recognize in Opioid Use Disorder. It is not unheard for an individual to backslide one or more times into substance abuse. Patience and love will be the most valuable response if the aim is to lead the abuser to a full and rewarding life.

Treatment of Opioid Use Disorder

Treatment of Opioid Use Disorder depends on what point the disease is caught. If a patient suspected of Opioid Use Disorder is showing signs of acute intoxication then a hospital stay or longer-term care may be required to support withdrawal (Blanco, Iza, Schwartz, Rafful, Wang, & Olfson, 2013). This would be a necessary first-step towards getting the disorder under control and treating it effectively.

The treatment of Opioid Use Disorder will likely incorporate both pharmacological and psychotherapy. Withdrawal and detoxification should be overseen by a physician. The goal is to safely ameliorate acute symptoms and support the patient as he or she enters an appropriate facility. At the beginning stages of opioid withdrawal methadone or buprenorphine have been found to successful minimize withdrawal symptoms that can be very unpleasant. There are several other medications that have recently been found to be helpful as well. It is important for the physician to fully assess the presence of other substances as well so that proper withdrawal treatment can be planned.

Once the patient has completed withdrawal then a regimen of psychosocial and pharmacological therapies may begin. Behavioral therapies are an essential part of a comprehensive treatment plan to prevent opioid use long-term. The most common therapeutic choices are contingency management, cognitive behavioral therapy, psychodynamic psychotherapy, family and group therapies and attendance in self-help groups.

The purpose of behavior therapies is to help the substance abuser recognize and admit that they have a problem; and then work through any underlying causes that would result in the individual turning to opiates. Psychotherapy is also intended to help the addictive person find positive replacements for the negative, destructive behavior; and identify triggers that will be easily recognizable as the precursors to substance abuse. In this way it is hoped that the substance abuser can then create scenarios of avoidance and act on these when faced with a desire to return to opioid use. Group therapy is an excellent way for a substance abuser to understand that he or she is not alone in the fight to stay sober; and perhaps gain insight on effective methodologies for doing so.

Although pharmaceuticals are recommended for the withdrawal process; after this it is best not to substitute opioids with any other form of medication (Miller, 2012).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Blanco, C.; Iza, M.; Schwartz, R.; Rafful, C.; Wang, S.; & Olfson, M. (2013). Probability and predictors of treatment-seeking for prescription opioid use disorders: a national study. Drug and alcohol dependence: Vol. 131, Iss. 1-2, p. 143.

Martins, S.; Fenton, M. ; Keyes, K.; Blanco, C.; Zhu, H.; & Storr, C. (2012). Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychological medicine, Vol. 42, Iss. 6, pp. 1261 – 1272.

Miller, S. (2012). Prescription opioid use disorder: a complex clinical challenge. Current Psychiatry; p. 15.

Wu, L.; Blazer, D; Li, T.; Woody, George, E. (2011). Treatment use and barriers among adolescents with prescription opioid use disorders. Addictive behaviors, Vol. 36, Iss.12, pp. 1233 – 1239.

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