Why Is Opioid Use Disorder (Sometimes Called "Opioid Abuse") Underdiagnosed?

October 12, 2022

Table of Contents

Opioid use disorder is often underdiagnosed for multiple reasons, including provider inexperience, stigma, and lack of awareness.

Regardless of the reason, underdiagnosis is a big problem. Addiction disorders respond very well to treatment, but the sooner it's provided, the better.

We’ve outlined how opioid use disorder is diagnosed and what you can do if you think you or a loved one have a problem with a substance.

How Is Opioid Use Disorder Diagnosed?

The medical and psychiatric professions use criteria from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose substance use disorders and other behavioral health conditions.[1]

For substance use disorders, these criteria focus on the following:

  • Physical symptoms: Two common signs are needing more medication to get the same effect and experiencing withdrawal symptoms when the substance is unavailable.
  • Psychological signs: The substance overtakes other life priorities like home, work, school, or social obligations.

Out of 11 criteria, meeting 2 merits the diagnosis of a mild opioid use disorder, whereas meeting over 6 criteria constitutes the diagnosis of a severe opioid use disorder.

Why Is Opioid Use Disorder Underdiagnosed?

The reasons vary greatly, but these are issues people often cite:

Lack of Awareness

Most patients do not approach a medical provider with addiction diagnostic criteria in mind.

Some people become concerned about cravings or withdrawal symptoms without knowing that opioid use is driving them. Others recognize popular images of addiction in their own experience, such as “life becoming unmanageable” or “hitting rock bottom” (core parts of Alcoholics Anonymous and Narcotics Anonymous language).

Patients may also not recognize signs and symptoms of dependence that are less widely known, such as increased generalized pain despite increased doses (sometimes due to opioid-induced hyperalgesia), low energy and mood when stopping opioids, and even erectile dysfunction.

Stigma & Misconceptions 

Due to stigma and fear of repercussions like dismissal from care, individuals may be hesitant to share their opioid struggles with medical providers. 

Poor Provider Training

Many medical providers are not specifically trained to diagnose and treat opioid use disorder. They may not recognize the early signs of problematic dependence.

In particular, pain management specialists often view the success of opioid prescriptions through the lens of pain control. Addiction specialists may see the more subtle risks and behaviors that raise concerns before a full-blown substance use disorder develops.[2]

Lack of Access 

Some individuals do not have access to primary care providers who might recognize problematic opioid use, much less specialists in substance use disorders who can help determine the line between expected side effects of opioids and problematic use.

How Can I Tell if My Reaction to Opioids Is Normal or Problematic?

The line between the expected effects of opioids and problematic use can be blurry.

Within a few weeks of taking opioids, most people develop tolerance.[3] They need more of the same medication to produce an impact that came with smaller doses. This is normal, and does not necessarily indicate a “use disorder”.

Anyone taking opioids regularly over a long period will likely experience withdrawal symptoms and cravings when opioids are unavailable. This is called physical dependence, and it's a sign of the brain's adaptation to the constant presence of opioids. This also does not necessarily indicate a “use disorder”.

The development of dependence and withdrawal symptoms are worrisome signs as they can be a first step toward progressing to a use disorder. However, a “use disorder” is more than just physical dependence: Opioid use disorder (commonly also called addiction) is diagnosed when dependence on opioids progresses to impairing life activities such as work, school, or social relationships.

When Is the Best Time to Diagnose & Treat Problematic Opioid Use?

The best time to consult a specialist about potential dependence or addiction is when an individual feels there might be a problem with opioids that is impacting their life activities or functioning.

This can include diverse red flags such as these:

  • Needing opioids to function at work or school or during the day 
  • Worsening pain rather than improved pain with increasing doses
  • Prioritizing opioids over friends and family
  • Feeling threatened by the idea of not having access to opioids

There is no need to wait until dependence evolves into a crisis (sometimes called “hitting rock bottom”). By seeking early care, people with problematic opioid use can prevent progression to a full blown OUD. If you are on chronic opioids for any reason, even if things are going well, its best to have a provider that you know and trust in case things change or you ever have concerns about your use. 

What to Do if You Think You Have a Problem With Opioids 

Addiction is a treatable disorder.[4] Every day, people enter treatment and learn to manage their use disorders.

No single treatment is right for everyone.[5] But many people benefit from Medication for Addiction Treatment (MAT), where pharmaceutical solutions amend brain chemistry and therapy helps people build a new life.[6]

If you think you have an “addiction” to opioid medications or to any substance for that matter, talk to your doctor about getting the support and treatment that's right for you.

Header Photo by Gustavo Fring from Pexels

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

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Citations

  1. DSM-5 Criteria for Diagnosis of Opioid Use Disorder. It Mattrs. https://www.asam.org/docs/default-source/education-docs/dsm-5-dx-oud-8-28-2017.pdf?sfvrsn=70540c2_2. Accessed August 2022.
  2. Merging the Wisdom of Pain Medicine and Addiction Medicine to Optimize Outcomes. KevinMD. https://www.kevinmd.com/2021/01/merging-the-wisdom-of-pain-medicine-and-addiction-medicine-to-optimize-outcomes.html. January 2021. Accessed August 2022.
  3. Long-Term Opioid Treatment. AMA Journal of Ethics. https://journalofethics.ama-assn.org/article/long-term-opioid-treatment/2013-05. May 2013. Accessed August 2022.
  4. Treatment and Recovery. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery. July 2020. Accessed August 2022.
  5. Treatment Approaches for Drug Addiction. National Institute on Drug Abuse. https://nida.nih.gov/publications/drugfacts/treatment-approaches-drug-addiction. January 2019. Accessed August 2022. 
  6. Opioid Misuse and Addiction. National Library of Medicine. https://medlineplus.gov/opioidmisuseandaddiction.html. April 2018. Accessed August 2022.

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