Opioid Abuse and Overdose: Keep Your Patients Safe: Identify Patients at Risk, Ensure an Accurate Evaluation, and Treat the Underlying Disorder

By Patkar, Ashwin A.; Weisler, Richard H. | Current Psychiatry, August 2017 | Go to article overview

Opioid Abuse and Overdose: Keep Your Patients Safe: Identify Patients at Risk, Ensure an Accurate Evaluation, and Treat the Underlying Disorder


Patkar, Ashwin A., Weisler, Richard H., Current Psychiatry


Opioid abuse and overdose are large and growing problems, and in recent years the numbers have been staggering. Overdose deaths related to opioids increased from 28,647 in 2014 to 33,091 in 2015 (Figure, page 10). (1) More than 2 million individuals in the United States had opioid use disorder in 2015,2 and approximately 80% of them received no treatment, (3) even though effective treatment could reduce the scope of abuse. (4,5)

Although psychiatrists typically are not the primary prescribes of opioid medications, they often treat psychiatric disorders in patients with chronic pain who take prescription opioids. A recent study found that, despite representing only 16% of the adult population, adults with mental health disorders receive more than one-half of all opioid prescriptions distributed each year in the United States. (6) Therefore, psychiatrists must be aware of risk assessment strategies for patients receiving opioids.

In this article, we provide recommendations for managing individuals with opioid use disorder, including:

* how to identify risk factors for opioid use disorder and use screening tools

* how to evaluate a patient with suspected opioid use disorder and make the diagnosis

* how to treat a patient with opioid use disorder, including a review of approved pharmaceutical agents.

Risk factors for opioid abuse and overdose

Patients with a history of mental health and/or substance use disorders or at least 3 months of prescribed opioid treatment are at risk for opioid abuse. Those taking a high daily dose of opioids or who have a history of overdose are at risk for overdose from opioid abuse (Table l). (7-12) Standardized tools, such as the Opioid Risk Tool, can be used to screen to assess risk for opioid abuse among individuals prescribed opioids for treatment of chronic pain. (12) However, clinicians must be aware that even patients without characteristic risk factors can become dependent on opioids and/or be at risk for an accidental or intentional overdose. For example, opioid therapy following surgical procedures, even in patients who do not have a history of opioid use, increases risk of developing opioid use disorder. (13)

Evaluation and diagnosis

DSM-5 criteria define 3 degrees of opioid use disorder, depending on how many of the following traits a patient exhibits (mild, 2 to 3; moderate, 4 to 5; and severe, [greater than or equal to] 6) (14):

* taking more than the initially intended quantities of opioids or for a longer period of time than intended

* continuous attempts to reduce or otherwise manage opioid use or desires to do so

* a great deal of time using, recovering from, or acquiring opioids

* reports of strong cravings to use opioids

* failing to meet personal objectives at home, work, or school

* continued opioid use even though it causes recurrent social problems

* reduction or elimination of activities the patient once considered important due to opioid use

* opioid use in situations where it is physically dangerous

* continued opioid use despite persistent psychological or physiologic problems despite knowing that continued use is causing or worsening those problems

* tolerance to opioids (not consequential for the diagnosis if the patient is taking opioids under appropriate medical supervision)

* withdrawal or use of opioids (or related substances) to prevent withdrawal (not consequential for the diagnosis if the patient is taking opioids under appropriate medical supervision).

Clinicians should be vigilant for symptoms of opioid use or withdrawal, such as needle marks and weight loss, during the interview (Table 2). High-risk populations that require regular screening include individuals with a history of opioid use disorder, patients taking chronic pain medication, and psychiatric patients. …

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