“In 2017, more than 47,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid,” the National Institute on Drug Abuse reported in January. “That same year, an estimated 1.7 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 652,000 suffered from a heroin use disorder.”
In a recent podcast with BMJ Best Practice, the medical director of The Farley Center at Williamsburg Place, Jonathan Lee, gave an informative overview of opioid use disorder (OUD). Dr. Lee started by explaining the eleven diagnostic criteria listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders which serves as a universal authority for psychiatric diagnoses in the United States.
The first two are “opioids are often taken in larger amounts or over a longer period than was intended,” and “there is a persistent desire or unsuccessful efforts to cut down or control opioid use.” The following two criteria are present if “a great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects,” and if the individual experiences “craving, or a strong desire or urge to use opioids.”
The next three OUD criteria describe the social implications of opioid misuse. Recurrent opioid use results in a failure to fulfill major role obligations at work, school, or home. Opioid use is continued despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the opioid, and important social, occupational, or recreational activities are given up or reduced because of opioid use.
The last three describe serious consequences for health and well-being of the user. Recurrent opioid use occurs in situations in which it is physically hazardous. There is continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Tolerance (needing markedly increased amounts of opioids to achieve intoxication) and the presence of opioid withdrawal syndrome (compulsive use to relieve or avoid withdrawal symptoms).
While this is the basic framework for an OUD diagnosis, we should not forget that addiction is a complex disease. In fact, Dr. Lee recently categorized the ongoing opioid epidemic as a “wicked problem” in a presentation as part of the Williamsburg Place Lecture Series. Wicked problems arise from “complex systems with components that interact in poorly understood and unpredictable ways.” Interventions into such a system “produce downstream consequences that cannot be known in advance.”
In other words, treating addiction is complicated. Each patient is different and there is no single test for opioid use disorder. Clinicians need to obtain a comprehensive history and a psychiatric assessment. Patients with a genetic disposition and traumatic life experiences have an elevated addiction risk when exposed to drugs and alcohol.
Addiction is a biopsychosocial phenomenon. Biology, sociology, and psychology all play important roles in understanding addictive behavior. Opioid misuse has to be assessed in the context of social circumstances, life experiences, and other personal, biological, and cultural variables. Co-occurring conditions like anxiety, depression, and trauma are often the driving force behind the substance abuse. “One of the diagnostic pitfalls is not always putting in enough effort to obtain important collateral information—from family members and friends for example,” explained Dr. Lee.
Medication-assisted therapy (MAT) can be part of a comprehensive treatment approach. MAT combines behavioral therapy and particular medications to treat opioid use disorder. Three FDA-approved medications are currently used to treat opioid addiction:
- Methadone, a clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it.
- Naltrexone, an office-based non-addictive opioid antagonist that blocks the effects of other narcotics.
- Buprenorphine, an office-based opioid agonist/antagonist that blocks other narcotics while reducing withdrawal risk.
Since MAT involves the use of opioids to fight opioid addiction, strict supervision is crucial. “Don’t just leave them to their own devices,” warned Dr. Lee. “Accountability is very important.” Dr. Lee also emphasized the importance of involving the family members in the recovery of their loved one. “Families are often invited to be part of the treatment, so they are not only looking at the patient but the whole family dynamic and how addiction affects them all.”
If you or someone you know is struggling with substance use and could benefit from addiction treatment services, please contact The Farley Center at Williamsburg Place at 800.582.6066 or fill out our admissions request form.