The rampant opioid misuse battering the nation represents one of the most virulent threats to employee welfare in the more than 100-year history of workers’ compensation protections. Equipping key players with an understanding of what to look for and how to respond will lead to better chances of deterring the abuse of opioid analgesics that has proven so costly to workers’ wellbeing.
To best respond to the crisis, we need to be clear about what opioid use disorder
(OUD) is and how we identify it. By spotting misuse sooner, prescribers have a
greater ability to intervene and perhaps prevent another of the more than 183,000
fatal opioid overdoses that occurred from 1999 through 2015. Earlier intervention
can also help to avoid the many other poor outcomes that can result from misusing
opioids. The number of fatalities, as alarming as it is, veils the full scope of the
problem. For every fatal overdose there are 11 treatment admissions for abuse, 28
emergency department visits for misuse or abuse, 133 people who misuse opioids or
are dependent upon them, and 689 nonmedical users, according to statistics adapted
from the Substance Abuse and Mental Health Services Administration (SAMHSA),
which is the primary federal agency responsible for substance abuse and mental
What is opioid use disorder?
The way we define issues with opioid use has evolved over time. In recent years, the view of addiction has shifted from that of a poor choice pathway to one of disease state management. For example, the American Society of Addiction Medicine describes addiction as a “primary, chronic, neurobiologic disease, with
genetic, psychosocial, and environmental factors influencing its development and manifestation.” Further advancing this disease state approach, the terms “opioid addiction” and “dependence” are giving way to a broader definition of the condition
known as “opioid use disorder.” The American Psychiatric Association does not classify addiction within its Diagnostic and Statistical Manual of Mental Disorders, or DSM–5. Instead, when updating the DSM in 2013, it replaced two separate disorders—
substance abuse and substance dependence—with a single category of “substance use disorder” (under which specific substances such as opioids are further differentiated).
Regardless of the definitions used, OUD can present complex treatment challenges, and a multimodal approach is often required.
How can prescribers identify opioid use disorder?
Under the diagnostic criteria found in the DSM–5, a person is designated as having
OUD if, within a 12-month period, he or she exhibits a problematic pattern of opioid
use that meets with at least two of nine to 11 characteristics and that pattern of
use leads to clinically significant impairment or distress. The characteristics include
experiencing craving or a strong desire to use the opioid, continued use despite
harm, or taking the medication for a longer period of time or in larger amounts than
intended by prescription. Prescribers can monitor for these characteristics or behavior
patterns in their patients who are taking opioids. Similarly, prescribers can incorporate
urine drug screening as a best practice for patients who are taking opioids to rule out the inappropriate use of the prescription or illicit drugs as well as identify cases of
opioid prescription diversion.