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

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April 18, 2022

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The opioid epidemic is the topic of daily news reports throughout America. Yet “opioid use disorder” (the formal name for opioid dependence or opioid addiction) is often underdiagnosed, leading to delays in offering treatment to individuals who struggle with opioids. 

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 (called the DSM-V) to diagnose substance use disorders and other behavioral health conditions. For substance use disorders, these criteria focus on physical symptoms (such as needing more medication to get the same effect and experiencing withdrawals when the substance is not available), as well as psychological signs such as the substance dependence overtaking other life priorities like home, work, school, or social obligations. Out of eleven total criteria, meeting two criteria merits the diagnosis of mild opioid use disorder, where over six criteria makes the diagnosis of severe opioid use disorder. 

However, most patients do not approach a medical provider with these 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). Sometimes an individual, friend, or family simply “know it when they see it.” While only the DSM5 criteria are recognized for medical diagnosis and treatment, all of these red flags are helpful if they inspire someone to seek care for issues with opioid dependence. 

Why is opioid use disorder underdiagnosed?

Opioid use disorder is underdiagnosed for a number of reasons. Many medical providers are not specifically trained to diagnose and treat opioid use disorder and so may not recognize the early signs of problematic dependence, including sleep disturbances, anxiety, rebound pain, and recurrent withdrawal between doses. In particular, pain management specialists often view the success of opioid prescriptions through the lens of pain control, whereas addiction specialists may see the more subtle risks and behaviors that raise concerns before a full-blown substance use disorder develops.

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

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 expected effects of opioids and problematic use can be blurry. Any person who takes opioids regularly over a long period of time is likely to experience withdrawal and cravings when opioids are not available - this is called physical dependence. Opioid use disorder (commonly called addiction) can be diagnosed when dependence on opioids progresses to the point of impairing life activities such as work, school, and social relationships.  

However, opioid dependence without the hallmarks of addiction may be problematic if the opioids are coming from illegal sources, are used by injection or other risky routes of administration, or are taken for different reasons than prescribed (for example if an individual complains of pain to get opioids but actually takes them to “get high” or deal with anxiety, trauma, stress, and depression). 

Unfortunately, the external environment sometimes plays a key role in the transition from physical dependence to outright addiction; many patients recall that their opioid use was stable and medically appropriate until a provider closed a practice or moved away, at which point dependence on opioids rapidly turned into a life-altering problem.

When is the best time to diagnose and treat problematic opioid use?

The best time to consult a specialist about potential dependence or addiction is the moment that an individual feels there may be a problem with opioids. This can include diverse red flags such as needing opioids to function, worsening pain rather than improved pain with increasing doses, prioritizing opioids over friends and family, and 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”) to get help; by seeking early care, people with problematic opioid use can divert out of a predictable pattern of abuse and enter treatment before the issue progresses to compromise work, family, relationships, and health. 

At the same time, people who find themselves in crisis with opioids are equally qualified for treatment. These crises might include the transition to injected opioids, overdose, and illness or injury due to opioid use (such as skin or deep infections from injection). 

Whatever stage of opioid dependence they are in, all individuals deserve access to caring, competent services to assist them to recover. Telemedicine options like Bicycle Health can open up access to care for people who are too far from providers or cannot take time away from work to travel to frequent appointments.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Header Photo by Gustavo Fring from Pexels

Dr. Julie Craig, MD

Dr. Julie Craig is board certified in family medicine (2010) and addiction medicine (2015). She attended medical school at Oregon Health & Science University, then completed the Northern New Mexico Family Medicine Residency Program in Santa Fe.

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