Opioid Use Disorder Diagnostic Criteria

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Opioid Use DisorderDiagnostic CriteriaA problematic pattern of opioid use leading to clinically significant impairment or distress, as manifestedby at least two of the following, occurring within a 12-month period:1. Opioids are often taken in larger amounts or over a longer period than was intended.2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recoverfrom its effects.4. Craving, or a strong desire or urge to use opioids.5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.6. Continued opioid use despite having persistent or recurrent social or interpersonal problems causedor exacerbated by the effects of opioids.7. Important social, occupational, or recreational activities are given up or reduced because of opioiduse.8. Recurrent opioid use in situations in which it is physically hazardous.9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychologicalproblem that is likely to have been caused or exacerbated by the substance.10. Tolerance, as defined by either of the following:a.A need for markedly increased amounts of opioids to achieve intoxication or desired effect.b.A markedly diminished effect with continued use of the same amount of an opioid.Note: This criterion is not considered to be met for those taking opioids solely underappropriate medical supervision.11. Withdrawal, as manifested by either of the following:a.The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set foropioid withdrawal).b.Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.Page 1Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013).American Psychiatric Association All Rights Reserved.

Note: This criterion is not considered to be met for those individuals taking opioids solelyunder appropriate medical supervision.Specify if: In early remission: After full criteria for opioid use disorder were previously met, none ofthe criteria for opioid use disorder have been met for at least 3 months but for less than 12months (with the exception that Criterion A4, “Craving, or a strong desire or urge to useopioids,” may be met). In sustained remission: After full criteria for opioid use disorder were previously met, noneof the criteria for opioid use disorder have been met at any time during a period of 12months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urgeto use opioids,” may be met).Specify if: On maintenance therapy: This additional specifier is used if the individual is taking aprescribed agonist medication such as methadone or buprenorphine and none of the criteriafor opioid use disorder have been met for that class of medication (except tolerance to, orwithdrawal from, the agonist). This category also applies to those individuals beingmaintained on a partial agonist, an agonist/antagonist, or a full antagonist such as oralnaltrexone or depot naltrexone. In a controlled environment: This additional specifier is used if the individual is in anenvironment where access to opioids is restricted.Coding based on current severity: Note for ICD-10-CM codes: If an opioid intoxication, opioidwithdrawal, or another opioid-induced mental disorder is also present, do not use the codes below for opioiduse disorder. Instead, the comorbid opioid use disorder is indicated in the 4th character of the opioidinduced disorder code (see the coding note for opioid intoxication, opioid withdrawal, or a specific opioidinduced mental disorder). For example, if there is comorbid opioid-induced depressive disorder and opioiduse disorder, only the opioid-induced depressive disorder code is given, with the 4th character indicatingwhether the comorbid opioid use disorder is mild, moderate, or severe: F11.14 for mild opioid use disorderwith opioid-induced depressive disorder or F11.24 for a moderate or severe opioid use disorder with opioidinduced depressive disorder.Specify current severity: 305.50 (F11.10) Mild: Presence of 2–3 symptoms. 304.00 (F11.20) Moderate: Presence of 4–5 symptoms.Page 2Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013).American Psychiatric Association All Rights Reserved.

304.00 (F11.20) Severe: Presence of 6 or more symptoms.SpecifiersThe “on maintenance therapy” specifier applies as a further specifier of remission if the individual is both inremission and receiving maintenance therapy. “In a controlled environment” applies as a further specifier ofremission if the individual is both in remission and in a controlled environment (i.e., in early remission in acontrolled environment or in sustained remission in a controlled environment). Examples of theseenvironments are closely supervised and substance-free jails, therapeutic communities, and locked hospitalunits.Changing severity across time in an individual is also reflected by reductions in the frequency (e.g., days ofuse per month) and/or dose (e.g., injections or number of pills) of an opioid, as assessed by the individual’sself-report, report of knowledgeable others, clinician’s observations, and biological testing.Diagnostic FeaturesOpioid use disorder includes signs and symptoms that reflect compulsive, prolonged self-administration ofopioid substances that are used for no legitimate medical purpose or, if another medical condition is presentthat requires opioid treatment, that are used in doses greatly in excess of the amount needed for thatmedical condition. (For example, an individual prescribed analgesic opioids for pain relief at adequate dosingwill use significantly more than prescribed and not only because of persistent pain.) Individuals with opioiduse disorder tend to develop such regular patterns of compulsive drug use that daily activities are plannedaround obtaining and administering opioids. Opioids are usually purchased on the illegal market but mayalso be obtained from physicians by falsifying or exaggerating general medical problems or by receivingsimultaneous prescriptions from several physicians. Health care professionals with opioid use disorder willoften obtain opioids by writing prescriptions for themselves or by diverting opioids that have been prescribedfor patients or from pharmacy supplies. Most individuals with opioid use disorder have significant levels oftolerance and will experience withdrawal on abrupt discontinuation of opioid substances. Individuals withopioid use disorder often develop conditioned responses to drug-related stimuli (e.g., craving on seeing anyheroin powder–like substance)—a phenomenon that occurs with most drugs that cause intense psychologicalchanges. These responses probably contribute to relapse, are difficult to extinguish, and typically persistlong after detoxification is completed (Fatseas et al. 2011b).Associated Features Supporting DiagnosisOpioid use disorder can be associated with a history of drug-related crimes (e.g., possession or distributionof drugs, forgery, burglary, robbery, larceny, receiving stolen goods). Among health care professionals andindividuals who have ready access to controlled substances, there is often a different pattern of illegalactivities involving problems with state licensing boards, professional staffs of hospitals, or otherPage 3Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013).American Psychiatric Association All Rights Reserved.

administrative agencies. Marital difficulties (including divorce), unemployment, and irregular employmentare often associated with opioid use disorder at all socioeconomic levels.PrevalenceThe 12-month prevalence of opioid use disorder is approximately 0.37% among adults age 18 years andolder in the community population (Compton et al. 2007). This may be an underestimate because of thelarge number of incarcerated individuals with opioid use disorders (Compton et al. 2010). Rates are higherin males than in females (0.49% vs. 0.26%), with the male-to-female ratio typically being 1.5:1 for opioidsother than heroin (i.e., available by prescription) and 3:1 for heroin. Female adolescents may have a higherlikelihood of developing opioid use disorders (Wu et al. 2009). The prevalence decreases with age, with theprevalence highest (0.82%) among adults age 29 years or younger, and decreasing to 0.09% among adultsage 65 years and older. Among adults, the prevalence of opioid use disorder is lower among AfricanAmericans at 0.18% and overrepresented among Native Americans at 1.25%. It is close to average amongwhites (0.38%), Asian or Pacific Islanders (0.35%), and Hispanics (0.39%) (Wu et al. 2009).Among individuals in the United States ages 12–17 years, the overall 12-month prevalence of opioid usedisorder in the community population is approximately 1.0%, but the prevalence of heroin use disorder isless than 0.1%. By contrast, analgesic use disorder is prevalent in about 1.0% of those ages 12–17 years,speaking to the importance of opioid analgesics as a group of substances with significant healthconsequences (Substance Abuse and Mental Health Services Administration 2011).The 12-month prevalence of problem opioid use in European countries in the community population ages15–64 years is between 0.1% and 0.8%. The average prevalence of problem opioid use in the EuropeanUnion and Norway is between 0.36% and 0.44% (European Monitoring Centre for Drugs and Drug Addiction2010).Development and CourseOpioid use disorder can begin at any age, but problems associated with opioid use are most commonly firstobserved in the late teens or early 20s. Once opioid use disorder develops, it usually continues over a periodof many years, even though brief periods of abstinence are frequent. In treated populations, relapsefollowing abstinence is common. Even though relapses do occur, and while some long-term mortality ratesmay be as high as 2% per year, about 20%–30% of individuals with opioid use disorder achieve long-termabstinence. An exception concerns that of military service personnel who became dependent on opioids inVietnam; over 90% of this population who had been dependent on opioids during deployment in Vietnamachieved abstinence after they returned, but they experienced increased rates of alcohol or amphetamineuse disorder as well as increased suicidality (Price et al. 2001).Page 4Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013).American Psychiatric Association All Rights Reserved.

Increasing age is associated with a decrease in prevalence as a result of early mortality and the remission ofsymptoms after age 40 years (i.e., “maturing out”). However, many individuals continue have presentationsthat meet opioid use disorder criteria for decades (Hser et al. 2007).Risk and Prognostic FactorsGenetic and physiologicalThe risk for opiate use disorder can be related to individual, family, peer, and social environmental factors(Kendler et al. 2003; Tsuang et al. 1998), but within these domains, genetic factors play a particularlyimportant role both directly and indirectly. For instance, impulsivity and novelty seeking are individualtemperaments that relate to the propensity to develop a substance use disorder but may themselves begenetically determined. Peer factors may relate to genetic predisposition in terms of how an individualselects his or her environment.Culture-Related Diagnostic IssuesDespite small variations regarding individual criterion items, opioid use disorder diagnostic criteria performequally well across most race/ethnicity groups. Individuals from ethnic minority populations living ineconomically deprived areas have been overrepresented among individuals with opioid use disorder.However, over time, opioid use disorder is seen more often among white middle-class individuals, especiallyfemales, suggesting that differences in use reflect the availability of opioid drugs and that other socialfactors may impact prevalence. Medical personnel who have ready access to opioids may be at increasedrisk for opioid use disorder.Diagnostic MarkersRoutine urine toxicology test results are often positive for opioid drugs in individuals with opioid usedisorder. Urine test results remain positive for most opioids (e.g., heroin, morphine, codeine, oxycodone,propoxyphene) for 12–36 hours after administration. Fentanyl is not detected by standard urine tests butcan be identified by more specialized procedures for several days. Methadone, buprenorphine (orbuprenorphine/naloxone combination), and LAAM (L-alpha-acetylmethadol) have to be specifically tested forand will not cause a positive result on routine tests for opiates. They can be detected for several days up tomore than 1 week. Laboratory evidence of the presence of other substances (e.g., cocaine, marijuana,alcohol, amphetamines, benzodiazepines) is common. Screening test results for hepatitis A, B, and C virusare positive in as many as 80%–90% of injection opioid users, either for hepatitis antigen (signifying activeinfection) or for hepatitis antibody (signifying past infection). HIV is prevalent in injection opioid users aswell. Mildly elevated liver function test results are common, either as a result of resolving hepatitis or fromtoxic injury to the liver due to contaminants that have been mixed with the injected opioid. Subtle changesPage 5Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013).American Psychiatric Association All Rights Reserved.

in cortisol secretion patterns and body temperature regulation have been observed for up to 6 mont