CASE Sam M., age 48, is in your office for the first time in more than two years. He has gained a considerable amount of weight and appears a bit sluggish, and you wonder whether he's depressed. As you take a history, Sam reminds you that he was laid off 16 months ago and had been caring for his wife, who sustained a debilitating back injury. When you saw her recently, she told you she's back to work and pain-free. So you're taken aback when Sam asks you to refill his wife's oxycodone prescription for lingering pain that often keeps her up at night.
If Sam were your patient, would you suspect opioid dependence?
Dependence on opioid analgesics and the adverse consequences associated with it have steadily increased during the past decade. Consider the following:
• Between 2004 and 2008, the number of emergency department visits related to nonmedical prescription opioid use more than doubled, rising by 111%.1
• The increasing prevalence of opioid abuse has led to a recent spike in unintentional deaths,2 with the number of lives lost to opioid analgesic overdose now exceeding that of heroin or cocaine.3
• More than 75% of opioids used for nonmedical purposes were prescribed for someone else.4
The course of opioid use is highly variable. Some people start with a legitimate medical prescription for an opioid analgesic, then continue taking it after the pain subsides. Others experiment briefly with nonmedical prescription opioids or use them intermittently without adverse effect. Some progress from prescription opioids to heroin, despite its dangers.5 Still others experience a catastrophic outcome, such as an overdose or severe accident, the first time they use opioids.6 Rapid progression from misuse of opioids to dependence is most likely to occur in vulnerable populations, such as those with concurrent mental illness, other substance use disorders, or increased sensitivity to pain.7
Understanding the terms. Before we continue, a word about terminology is in order. Misuse generally refers to the use of a medication in a manner (ie, purpose, dose, or frequency) other than its intended use, whereas drug addiction is the repeated use of a drug despite resulting harm. Here we will use opioid dependence to mean a pattern of increasing use characterized by significant impairment and distress and an inability to stop, and opioid withdrawal to reflect a constellation of symptoms, such as insomnia, nausea, diarrhea, and muscle aches, that can follow physiological dependence (though not necessarily opioid dependence). Our definitions of these terms are consistent with those of the American Psychiatric Association (APA).8 Worth noting, however, is the fact that as the APA prepares for the publication of the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders, its Substance Disorder Work Group has proposed replacing the term opioid dependence with opioid use disorder to reduce the confusion associated with these definitions.9
Assessing Illicit Opioid Use: Start With a Targeted Question
Most patients who are opioid dependent do not seek treatment for it10 and are typically free of medical sequelae associated with drug addiction when they see family practitioners. The absence of self-reporting and obvious physical signs and symptoms, coupled with the increase in illicit use of prescription opioids, underscores the need for clinicians to identify patients who are abusing opioids and ensure that they get the help they need.
Screening tools. There are a number of screening tools you can use for this purpose—eg, CAGE-Adapted to Include Drugs (CAGE-AID) and Drug Abuse Screening Test (DAST)11,12—but they have not been found to be significantly better than a careful substance abuse history.13
Straightforward questions. You can start by asking, "Do you take any medications for pain?" If the answer is Yes, get the name of the drug and inquire about the frequency of use and the route, the amount typically taken, and the duration of the current use pattern. Ask specifically about opioids when taking a substance abuse history. After a question about alcohol use, you can say, "Do you use any other drugs in a serious way? Marijuana? Opioids, like Percocet, Vicodin, or Oxycontin?" Although it can be very difficult to detect opioid dependence if the patient is not forthcoming, other likely indicators of drug-seeking behavior should trigger additional questions. (See "Opioid dependence: Red Flags to Keep in Mind."14-16)
"Brief" protocols. Recent studies of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have found that the simple, time-limited interventions they offer (visit www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf to learn more) lead to a reduction in self-reported illicit opioid use.17,18 Clinicians can readily incorporate SBIRT protocols into routine practice, as an evidence-based and often reimbursable approach to substance abuse.17