Assessment and Clinical Picture
Opioid use disorders can occur at any age,
including adolescence and the geriatric years, but most affected persons are
between 20 and 45 years. Neonates whose mothers are addicted can experi-ence
opioid withdrawal. Rarely, young children are affected with some cases of
dependence having been reported in persons who are 8 to 10 years of age. Males
are more commonly affected, with the male : female ratio typically being 3 or 4
A nonjudgmental and supportive yet firm approach to
these patients is especially important. They typically have en-gaged in
antisocial or other forms of problematic behavior. They are often embarrassed
or afraid to describe the extent of their behavior, and have extremely low
self-esteem. At the same time, they are prone to be impulsive, manipulative and
to act-out when frustrated. Communicating a feeling of nonjudgmental support in
the context of setting limits, along with a clear and informed effort to
provide appropriate help will encourage optimum thera-peutic opportunities.
Sclerosed veins (“tracks”) and puncture marks on
the lower por-tions of the upper extremities are common in intravenous users.
When these veins become unusable or otherwise unavailable, per-sons will
usually switch to veins in the legs, neck or groin. Veins sometimes become so
badly sclerosed that peripheral edema de-velops. When intravenous access is no
longer possible, persons will often inject directly into their subcutaneous
tissue (“skin-popping”) resulting in cellulitis abscesses, and
circular-appear-ing scars from healed skin lesions. Tetanus is a relatively
rare butextremely serious consequence of injecting into the subcutaneous
tissues. Infections also occur in other organ systems, including bacterial
endocarditis, hepatitis B and C, and HIV infection.
Persons who “snort” heroin or other opioids often
develop irritation of the nasal mucosa. Difficulties in sexual function are
common, as are a variety of sexually transmitted diseases. Males often
experience premature ejaculation associated with opioid withdrawal, and
impotence during intoxication or chronic use. Females commonly have
disturbances of reproductive function and irregular menses.
During dependence, routine urine toxicology tests
are often posi-tive for opioid drugs and remain positive for most opioids for
12 to 36 hours. Methadone and LAAM, because they are longer act-ing, can be
identified for several days. Fentanyl is not detected by standard urine tests
but can be identified by more specialized procedures. Oxycodone, hydrocodone
and hydromorphone are often not routinely included on urine toxicology tests
though they can be identified by gas chromatography/mass spectrom-etry. Testing
for fentanyl is not necessary in most programs, but needs to be performed in
assessing and treating health care pro-fessionals such as anesthesiologists who
have access to this drug. Concomitant laboratory evidence of other abuseable
substances such as cocaine, marijuana, alcohol, amphetamines and
benzodi-azepines is common.
Hepatitis screening tests are often positive,
either for hepa-titis B antigen (signifying active infection) or hepatitis B
and/or C antibody (signifying past infection). Mild to moderate eleva-tions of
liver function tests are common, usually as a result of chronic infection with
hepatitis C but also from toxic injury to the liver due to contaminants that
have been mixed with injected opioids, or from heavy use of other hepatotoxic drugs
such as alcohol. Low platelet count, anemia, or neutropenia, as well as
positive HIV tests or low CD-4 cell counts are often signs of HIV infection.
HIV is commonly acquired via the practice of sharing injection equipment, or by
unprotected sexual activity that may be related to the substance use disorder,
for example, exchanging sex for drugs or money to buy drugs.
Individuals who are dependent on “street” opioids
are usu-ally easy to diagnose due to the physical signs of intravenous use,
drug-seeking behavior, reports from independent observers, the lack of medical
justification for opioid use, urine test results, and the signs and symptoms of
intoxication or withdrawal.
The signs and symptoms of opioid withdrawal are
fairly specific, especially lacrimation and rhinorrhea, which are not
as-sociated with withdrawal from any other abuseable substances. Other
psychoactive substances with sedative properties such as alcohol, hypnotics, or
anxiolytics can cause a clinical picture that resembles opioid intoxication. A
diagnosis can usually be made by the absence of pupillary constriction, or by
the lack of response to a naloxone challenge. In some cases, intoxication is
due to opioids along with alcohol or other sedatives. In these cases the
naloxone challenge will not reverse all of the sedative drug effects.
Difficult diagnostic situations are seen among
persons who fabricate or exaggerate the signs and symptoms of a painful
ill-ness (such as kidney stones, migraine headache, back pain, etc.). Because
pain is subjective and difficult to measure, and because some of these
individuals can be very skillful and deceptive, diagnosis can be difficult and
time-consuming. Drugs that are obtained in such deceptions may be used by the
individual in the service of his/her dependence or abuse, or may be sold on the
il-licit drug market for profit. These individuals cause problems not only for
physicians, but also for patients with disorders that need opioids for pain
Persons with opioid dependence will often present
with psychiatric signs and symptoms such as depression or anxiety. Such
subjective distress often serves to motivate the patient to seek treatment, and
thus can be therapeutically useful. These symptoms can be the result of opioid
intoxication or withdrawal, or they might result from the pharmacological
effects of other substances that are also being abused such as cocaine,
alcohol, or benzodiazepines. They may also represent independent,
non-substance-induced psychiatric disorders that require long-term treatment.
The correct attribution of psychiatric symptoms that are seen in the context of
opioid dependence and abuse follows the principles that are outlined in the
substance-related section and other relevant parts of DSM-IV-TR.