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GeneesmiddelenverslavingPublished by: Domus Medica | SSMGLast published: 2011Assuétude aux médicamentsPublished by: Domus Medica | SSMGLast published: 2011The diagnosis of opioid use disorder is clinical, and therefore a thorough history and psychiatric and medical exam are essential for making a diagnosis and establishing severity of opioid use disorder. Appropriate laboratory tests can confirm drug use and may be required to confirm or assess associated complications. The immediate clinical priority is to identify and appropriately refer for any emergent medical or psychiatric problems, including overdose.[65] See Opioid overdose.
Otherwise, after establishing a diagnosis of opioid use disorder, it is important to ascertain whether there are any other comorbid substance use disorders (marijuana, benzodiazepines, and cocaine are the most common in people who misuse opioids), as well as any comorbid medical or psychiatric illnesses, such as bipolar disorder, ADHD, major depression, anxiety disorders, and personality disorders.[31][33] Clinical confirmation of these diagnoses should be made by a psychiatrist in the absence of positive substance use on toxicology screen. Take a social history to assess social issues which may require professional input; for example, living situation, employment, and risk of harm (e.g., physical, emotional, or sexual abuse by a family member or intimate partner).[66]
History
Make the diagnosis of opioid use disorder according to the relevant diagnostic criteria; for example, Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR) or International statistical classification of diseases and health related problems, 11th revision [ICD-11]).[1][2] See Criteria.
Clinical presentation
Patients with opioid use disorder may present with chronic constipation, weight loss, or symptoms of either tolerance or withdrawal. Tolerance may manifest as either blunting to the pleasurable effects of opioids, or adverse effects such as nausea and sedation. These can be seen as early as 2-3 days following continuous use of opioids, and the individual may seek to increase consumption of the drug to obtain similar drug-reinforcing effects.
Symptoms of withdrawal can occur within the same day or up to 72 hours after the last dose of opioid, depending on the half-life of the drug concerned. For example, heroin has a short half-life and is associated with withdrawal onset within 12 hours of last use, whereas withdrawal symptoms with methadone may manifest 24-74 hours after last use.[67] Initial manifestations include sneezing, yawning, and restless sleep. More severe manifestations include nausea, vomiting, abdominal cramps, diarrhea, backache, muscle spasm, hot and cold flashes, and insomnia. The duration of withdrawal symptoms is also correlated with the half-life of the opioid, with heroin withdrawal lasting 4-5 days, compared with 7-14 days or sometimes longer for methadone.[67]
Physical examination
A comprehensive physical exam is recommended as part of the initial assessment process, ideally before starting pharmacotherapy, or otherwise soon thereafter. [65][68]
Look for specific signs of opioid use. Signs will depend on whether the patient is acutely intoxicated, has a more chronic problem, has overdosed, or is going through withdrawal.
Opioid intoxication: somnolence, stupor, mood changes (e.g., euphoria followed by apathy and dysphoria), psychomotor retardation, impaired judgment, respiratory depression, slurred speech, and impairment of memory and attention.[2] Miosis may be absent if intoxication is due to synthetic opioids such as fentanyl.[2] In severe intoxication, coma may ensue.[2]
Opioid use disorder: miosis, sedation, or evidence of needle marks, scars, or skin necrosis at injection sites.
Opioid overdose: unconsciousness, pinpoint pupils, apnea (<10 breaths per minute), or very slow pulse rate (<40 beats per minute).
Opioid withdrawal: depressed or dysphoric mood, craving for an opioid, anxiety, nausea or vomiting, abdominal cramps, muscle aches, yawning, perspiration, hot and cold flashes, hypersomnia (typically in the initial phase) or insomnia, diarrhea, piloerection, and dilated pupils.[2] Use of a structured measure, for example clinical opiate withdrawal scale (COWS), may help to standardize documentation of signs and symptoms.[68] [ Clinical Opioid Withdrawal Scale (COWS) for adults and adolescents Opens in new window ] Neonates of opioid-dependent mothers often present with seizures during withdrawal.
Addiction Severity Index
The Addiction Severity Index (ASI) is a widely known structured interview designed to assess the patient's problem severity in seven areas of functioning: medical status, employment/support status, drug use, alcohol use, legal status, family/social relationships, and psychiatric status. Addiction Severity Index Opens in new window
Composite scores ranging from 0 (minimum severity) to 1 (maximum severity) are provided in each area to reflect problem severity in the last 30 days. These are based on subsets of items that have been found to be consistently associated with treatment outcome. A higher score on the ASI indicates a greater need for treatment.
The ASI is the most widely used clinical instrument in addiction treatment programs in the US, and is used for treatment planning and follow-up.[69] A brief version of the ASI (ASI-Lite) and a computerized version are also available.
Urine and saliva drug tests
A urine or saliva drug screen should be ordered initially if there is a clinical suspicion of drug use, as an adjunct to the screening interview.[68] Clear context and informed consent from the patient is required.[34] Testing for other substances such as cocaine, benzodiazepines, and methamphetamine in addition to testing for opioids is clinically important because these and other substances, especially benzodiazepines, can complicate treatment for opioid use disorder. Furthermore, co-occurring substance use disorders will require their own separate treatment plans.[68]
The Drug Screen 9 (DS-9) is one of the more common immunoassays, and tests a urine sample for opioids (oxycodone, hydrocodone, hydromorphone, morphine, and codeine only), cocaine, marijuana, benzodiazepines, phencyclidine, amphetamines, and barbiturates. The test will report "positive" for opioids in people who misuse opioids; however, it will not specifically identify which opioid has been taken.
Point of care tests (POCTs) may be appropriate in some circumstances (e.g., in primary care) as the initial screening test. They are conducted on a specimen of urine or saliva collected in a setting such as a practitioner’s office. POCTs use well-established immunoassay technologies for drug detection. The principal advantage of POCTs over laboratory screening tests, such as DS-9, is that the results are available in approximately 10 minutes. This fast turnaround allows practitioners to discuss the results with the patient during that office visit, and make clinical decisions and act appropriately that day. POCTs are also inexpensive and relatively easy to use with minimal training. Despite these benefits, laboratory testing is more accurate overall, and provides quantitative estimates of drugs and their metabolites.[70]
In the US, most POCTs are waived by Clinical Laboratory Improvement Amendments (CLIA) of the Food and Drug Administration (FDA). Tests may be waived by CLIAs if they are simple procedures that carry a low risk for an incorrect result. Most POCTs for opioids, including buprenorphine, are CLIA-waived.
A positive screen should be followed by a confirmatory urine test due to opioid sensitivity limitations (routine immunoassays do not usually detect synthetic or semisynthetic opioids [e.g., fentanyl, methadone, meperidine, tramadol]). Certain drugs (e.g., antibiotics) can also interfere with the screening test and produce false-positive results. The opioid confirmation urine test by gas chromatography-mass spectrometry is the most specific and sensitive test for identifying opioids.[70] This test will identify the specific opioid in the urine.
The detection times for opioids in the urine are 48-72 hours for most opioids, with the exception of methadone, which may be detected up to 7 days after use.[71][72] A positive opioid confirmation test should lead to a comprehensive evaluation for opioid use disorder if there are no legitimate prescriptions of opioids.
Drugs of misuse, including opioids, may also be detected in other body fluids, such as sweat, and in hair. Despite this, urine and saliva drug tests remain the most validated and clinically acceptable tests to date.
Other laboratory tests
Other tests that should be ordered initially include serum electrolytes, complete blood count, blood urea nitrogen/creatinine, and liver function tests (LFTs). Due to the risk of associated malnutrition, it is helpful to assess hematologic function and electrolytes. LFTs and renal function are important for assessing whether dosing adjustments are required for drug treatments. The American Society of Addiction Medicine recommends testing for tuberculosis, hepatitis, and HIV in all patients.[65]
Investigations for other sexually transmitted infections should be considered; for example, rapid plasma reagin for syphilis.[65] All women of childbearing potential should be tested for pregnancy.[65] Blood cultures are indicated if there are signs or symptoms suggestive of septicemia (e.g., high fever, altered mental state, and vital sign changes) or infective endocarditis (e.g., fever with heart murmur).
State prescription drug monitoring program (PDMP) data review
If drug treatment for opioid use disorder is being considered, a review of PDMP data is recommended to determine whether the patient is already in receipt of prescriptions for controlled substances (e.g., opioids, benzodiazepines) from other healthcare professionals.[68]
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