Clinical Psychiatry

Disorders due to use of opioids

Disorders due to use of opioids
ICD-10
F11		 Mental and behavioral disorders due to use of opioids
DSM-5-TR
F11.20		 Opioid Use Disorder, Moderate or Severe

1. Definition and nosology

Disorders due to use of opioids (ICD-11: 6C43; DSM-5-TR: F11.20 Opioid Use Disorder, OUD) — impaired control over opioid use (heroin, morphine, oxycodone, fentanyl, etc.) or harmful pattern of use. Medical and legal consequences are severe; mortality (overdose) is high.

2. History

  1. Dole V.P., Nyswander M. (1965) — initial studies of methadone maintenance therapy.
  2. 2010+ US opioid epidemic — starting with prescription opioids, leading to fentanyl overdose crisis.
  3. WHO, SAMHSA, NICE — opioid agonist maintenance therapy (OAT) is the gold standard.

3. Epidemiology

  • Global: approximately 60 million users (UNODC 2023); in the US in 2022, 80,000+ overdose deaths.
  • Sex: twice as common in males.
  • Comorbidity: MDD, anxiety, PTSD, BPD, HIV/HCV, cardiac.
  • Mortality: in treated OUD patients, 10–20 times higher compared to the population.

4. Etiology and pathogenesis

  • Heritability 50%.
  • Neurobiological — effect of the μ-opioid receptor system on the dopaminergic reward circuit.
  • Environment — prescription opioid availability, socioeconomic factors.
  • Pain syndromes — transition from prescription initiation to dependence.

5. Clinical features

  • Dependence syndrome (same criteria as AUD).
  • Intoxication — miosis, sedation, respiratory depression, hypotension, coma.
  • Overdose — respiratory depression is the main cause of death; naloxone is the antidote.
  • Withdrawal — onset 8–24 hours (short-acting), 36–72 hours (long-acting methadone); rhinorrhea, lacrimation, mydriasis, anxiety, tachycardia, abdominal cramps, diarrhea, piloerection.
  • Withdrawal is not life-threatening in adults (unlike alcohol/sedatives), but severe in neonates (NAS — Neonatal Abstinence Syndrome).

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR: same 11-criteria structure as AUD (mild/moderate/severe). Unlike DSM-5-TR, which uses a single severity scale, ICD-11 uses three separate categories: episode of harmful use, harmful pattern of use, and dependence. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Differences between sources

  • SAMHSA TIP 63 — Medications for Opioid Use Disorder.
  • NICE CG52 — opioid dependence.
  • WHO mhGAP.

6.3 Diagnostic algorithm

  • Clinical interview.
  • Toxicology screening (urine).
  • HIV, HCV, syphilis, pregnancy test.
  • Comorbidity and overdose history.
  • COWS (Clinical Opiate Withdrawal Scale) — withdrawal severity.

6.4 Differential diagnosis

Condition Distinguishing feature
Chronic pain (without dependence) Medical indication; pattern of use.
Other substance use (sedatives, alcohol) Toxicology.
Discontinuation signs (GI, piloerection) — differentiation from functional disorders Medical evaluation.

7. Examination and assessment

  1. Toxicology screening.
  2. COWS scale.
  3. HIV, HCV, HBV, syphilis.
  4. ECG (before starting methadone — QTc).
  5. Pregnancy test.

8. Treatment

8.1 OAT — opioid agonist therapy (gold standard)

  • Methadone (in a maintenance clinic, under daily supervision) — full μ-agonist; 60–120 mg/day; long half-life; QTc monitoring.
  • Buprenorphine/naloxone (Suboxone) — partial μ-agonist + naloxone; office-based prescription; low overdose potential; “induction” — started when mild or moderate withdrawal signs appear (COWS ≥ 8–12).
  • OAT significantly reduces mortality (Sordo L. et al. BMJ 2017;357:j1550 meta-analysis) and HIV transmission (MacArthur G.J. et al. BMJ 2012 meta-analysis).
  • OAT is superior to psychosocial intervention in mortality reduction; however, combination with psychosocial intervention (MI, CBT, contingency management, peer support, 12-step — see “Treatment methods”) is optimal.

8.2 Antagonist

  1. Naltrexone (oral 50 mg or IM Vivitrol 380 mg monthly) — patient must be abstinent for 7–10 days before initiation; in motivated patients or in the absence of formal maintenance programs.

8.3 Overdose management

  • Naloxone — IM/IN; widespread; “take-home” programs (community-based) reduce mortality.

8.4 In pregnancy

  • Methadone or buprenorphine — OAT is continued during pregnancy; detox is contraindicated (risk of relapse and pregnancy loss).
  • NAS intervention in the newborn — morphine or methadone.

8.5 Treatment methods

  • Methadone Maintenance Therapy (MMT) — Dole-Nyswander model; clinic-based.
  • Buprenorphine/Naloxone — Office-based; “Suboxone induction” protocol; the ceiling effect gives lower overdose potential.
  • Naloxone Take-Home Program — Community-based; antidote training for family.
  • Clinical Opiate Withdrawal Scale (COWS) — 11 items; crucial in induction.
  • Naltrexone IM (Vivitrol) — Monthly; in an abstinent patient.

8.6 Differences between sources

  1. SAMHSA TIP 63 (2021).
  2. NICE CG52 (opioid detoxification) and CG51 (psychosocial interventions).
  3. WHO — OAT is the gold standard, superior to abstinence-oriented approach.

9. Prognosis

  • Long-term stabilization and mortality reduction with OAT.
  • Comorbidity intervention is important.

10. Myths and misconceptions

Myth 1: “OAT (methadone, buprenorphine) replaces one addiction with another”

Evidence: OAT is medical treatment — significantly reduces mortality, HIV, crime, social disruption; “sensitive” anti-OAT stance is not evidence-based. WHO, SAMHSA, NICE — OAT is the gold standard.

Myth 2: “Detoxification is sufficient, OAT is not needed”

Evidence: detox alone 90%+ relapse; overdose mortality highest immediately after detox (loss of tolerance). OAT reduces mortality by 50%+.

Myth 3: “Ultra-rapid opioid detoxification (UROD) is effective”

Evidence: UROD is associated with deaths and serious adverse effects; no evidence of efficacy; SAMHSA and NICE do not recommend.

Myth 4: “Detox is needed in a pregnant woman”

Evidence: detox in pregnancy is contraindicated; OAT (methadone or buprenorphine) is maintained.

Myth 5: “Ibogaine or ayahuasca cures opioid addiction”

Evidence: No evidence supports this; ibogaine is associated with cardiac arrhythmia (QT prolongation) and fatal cases; not in standard practice.

Myth 6: “Naltrexone is first-line for OUD”

Evidence: SAMHSA TIP 63 — methadone and buprenorphine are more effective in reducing mortality; naltrexone in motivated abstinent patients.

Myth 7: “Naloxone take-home programs encourage use”

Evidence: Walley A.Y. et al. BMJ 2013 — community naloxone programs significantly reduce overdose deaths; do not increase use.

11. Sources

  • WHO. ICD-11. 6C43 Disorders due to use of opioids. 2024.
  • APA. DSM-5-TR. 2022.
  • SAMHSA. TIP 63: Medications for Opioid Use Disorder. 2021.
  • NICE CG52; NICE CG51.
  • MacArthur G.J. et al. Opioid substitution treatment and HIV transmission in people who inject drugs. BMJ 2012;345:e5945.
  • Sordo L., Barrio G., Bravo M.J. et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550.
  • Walley A.Y. et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution. BMJ 2013;346:f174.