Opioid use disorder: Simplifying diagnosis and treatment in primary care

ESTES PARK, COLO. – Have a low threshold for diagnosing opioid use disorder in chronic pain patients, Joshua Blum, MD, advised at a conference on internal medicine sponsored by the University of Colorado.

Be alert to so-called ‘chemical copers’ as they skate through your practice, he said. “Maybe they call in here and there for an early refill; maybe they go to the ER and get a few pills here and there. But they never really surface to the level where we recognize them as an opioid use disorder patient.

“Some of them cross that line where they go from use and maybe intermittent misuse to meeting the criteria for opioid use disorder. I think we underdiagnose this in our chronic pain patients. I spend a lot of time trying to convince patients who tell me I just need to take their pain seriously that, yes, you’re in pain, and you have a pain diagnosis, but you also have an opioid use disorder. Medicalizing it makes things a lot easier for them; it helps take away the blame,” said Dr. Blum, program coordinator for the HIV primary care clinic at Denver Health.

Dr. Joshua Blum

Chemical copers, a well-established term in addiction medicine, are not the glaringly obvious substance abusers or addicts. “They’re the ones in your practice who are on four or five different psychoactive drugs. They’ve never met a psychoactive drug they didn’t like. When they hurt their back, they’re on Flexoril [cyclobenzaprine]; they’re on an antidepressant, a neuropathic pain agent; they’re on a sedative or sleeping agent or trazadone. If you took the five pills they’re on, you’d be knocked out for 2 days. And they always go to the maximum dose,” he said.

As newly described in the the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, the diagnosis of opioid use disorder (OUD) requires that any 2 of the following 11 criteria be met:

• Taking more opioids than intended.
• Unsuccessful efforts to control opioid use.
• Spending a great deal of time in activities aimed at obtaining, using, or recovering from the effects of opioids.
• Craving opioids.
• Failure to fulfill major work, school, or home obligations because of opioid use.
• Worsening interpersonal problems related to opioid use.
• Giving up or reducing involvement in important social, recreational, or occupational activities because of opioid use.
• Recurrent use in situations where it’s physically hazardous, such as driving under the influence.
• Continued use despite physical or psychological problems stemming from opioid use.
• And finally, two special criteria applicable only if the opioid wasn’t prescribed and therefore isn’t being used under medical supervision: tolerance for opioids and withdrawal symptoms when they aren’t taken.

“Even if you can’t remember all these criteria, all you basically have to remember is ‘control.’ Many of these criteria describe situations where the patient is losing control of the drug. When they’re not controlling their drug use, the drug use is controlling them – and that’s addiction. All you need is for a patient to tell you ‘I tried to cut back on these drugs and I couldn’t,’ and that they’re experiencing some health consequences related to use yet still want to stay on the drugs, and, boom, they meet criteria for at least mild opioid use disorder,” he explained.

The standard treatment for OUD is opioid replacement therapy using methadone or buprenorphine (Subutex).

This approach is evidence-based therapy, Dr. Blum said, citing a recent meta-analysis of studies totaling nearly 123,000 opioid-dependent patients treated long-term with methadone and 16,000 treated with buprenorphine. The risk of all-cause mortality dropped by two-thirds when patients went on methadone, from 36.1% while out of treatment to 11.3% while on treatment. Similarly, all-cause mortality was 4.3% in patients on buprenorphine, compared with 9.5% in those out of treatment (BMJ. 2017 Apr 26;357:j1550. doi: 10.1136/bmj.j1550).

Access to methadone for treatment of OUD is available only through authorized methadone clinics, typically found only in big cities. But buprenorphine is a very useful alternative to methodone, Dr. Blum said.

“Buprenorphine is a schedule III drug that’s safe to prescribe in an office-based setting. It’s a partial mu opioid agonist with a ceiling effect, so people using buprenorphine can’t die from taking excessive amounts of it. You can even write refills on the prescription. And in head-to-head studies, it looks about as effective as moderate-dose methodone at 60 mg/day,” he said.

Opioid replacement therapy reduces euphoria and extinguishes craving. When methadone or buprenorphine is on board, saturating the opioid receptors, patients can use prescription or illicit opioids, but they won’t get high.

“People can really get their brains back online again,” Dr. Blum said.

Opioid maintenance therapy is consistent with the principles of harm reduction, a philosophy Dr. Blum said he embraces. Harm reduction can be summarized as “a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use, to abstinence,” according to the Harm Reduction Coalition.

“Primary care doctors are very used to meeting patients where they are. We don’t require perfectionism from our patients. We don’t withhold insulin from diabetic patients because they’re not exercising, for example. In the case of drug use, there is complete abstinence on one end and really severe misuse on the other, and there’s a whole lot of life that happens in the middle. We’re addressing that part in the middle,” Dr. Blum said.

Dr. Blum reported having no financial conflicts of interest regarding his presentation.