Opioid use disorder

Opioid use disorder (OUD) tests whether the counselor puts overdose prevention and medications for OUD first. On a case exam the best answer usually reduces mortality before it addresses insight.

Criteria at exam depth (paraphrased). OUD uses the general substance use framework: at least 2 of 11 criteria in 12 months; severity mild 2–3, moderate 4–5, severe 6+. Tolerance and withdrawal do not count when opioids are taken solely as prescribed under medical supervision. Specifiers include early and sustained remission, in a controlled environment, and on maintenance therapy (taking an agonist or antagonist medication, with no criteria met except tolerance or withdrawal to that medication).

Opioid withdrawal (paraphrased). After stopping or reducing heavy, prolonged use (or after an antagonist is given), 3 or more signs: dysphoric mood, nausea or vomiting, muscle aches, tearing or runny nose, dilated pupils, goosebumps or sweating, diarrhea, yawning, fever, insomnia. Withdrawal is miserable but rarely life-threatening in otherwise healthy adults, but it drives relapse. Intoxication/overdose: pinpoint pupils, drowsiness, slowed or stopped breathing. Respiratory depression is the killer.

Hinge differentials.

• Appropriate medical use: prescribed opioids taken as directed, stopped voluntarily; physiological dependence alone is not OUD.
• Progression signals OUD: escalation, early refills, multiple prescribers, or a shift from a prescription to illicit sources (heroin, illicit fentanyl).
• Sedative or alcohol co-use: combined respiratory depression sharply raises overdose risk.
• Substance-induced depression/anxiety: symptoms tied to use or withdrawal.

On the NCMHCE. Highest acute risks: using alone, no naloxone, unknown supply (fentanyl), sedative co-use, and loss of tolerance after abstinence (release from jail, detox, residential care, hospitalization). Provide naloxone and overdose education, especially during waiting periods before treatment begins. Medications for OUD are the standard of care: methadone (full agonist, dispensed through opioid treatment programs), buprenorphine (partial agonist, office-based), and naltrexone (antagonist; requires being opioid-free first). Detox alone is not treatment and raises later overdose risk. Address MAT stigma with accurate psychoeducation (stabilization, not "substituting one drug for another") while respecting autonomy; duration is individualized and long-term use is appropriate. Explore how use began (for some clients, prescribed pain treatment after surgery or injury). Match level of care (e.g., IOP with MOUD evaluation) and build aftercare with continuity of medication, transportation, peer support and relapse prevention. Screen suicide risk and infectious disease risk; refer for testing.

Clinical Pearl: Naloxone plus medications for OUD save lives; withdrawal is rarely fatal but overdose after lost tolerance can be. Prescribed-as-directed tolerance and withdrawal do not count toward OUD.