Additional information on opioid-related disorders
Additional Information on Opioid-Related Disorders
Associated Features and Disorders
Associated descriptive features and mental disorders.
Opioid Dependence is commonly associated with a history of drug-related crimes (e.g., possession or distribution of drugs, forgery, burglary, robbery, larceny, or receiving stolen goods). Among health care professionals and individuals who have ready access to controlled substances, there is often a different pattern of illegal activities involving problems with state licensing boards, professional staffs of hospitals, or other administrative agencies. Divorce, unemployment, or irregular employment is often associated with Opioid Dependence at all socioeconomic levels.
For many individuals, the effect of taking an opioid for the first time is dysphoric rather than euphoric, and nausea and vomiting may result. Individuals with Opioid Dependence are at risk for the development of mild to moderate depression that meets symptomatic and duration criteria for Dysthymic Disorder, and sometimes for Major Depressive Disorder. These symptoms may represent an Opioid-Induced Mood Disorder (see p. 405) or exacerbations of a preexisting primary depressive disorder. Periods of depression are especially common during chronic intoxication or in association with physical or psychosocial stressors that are related to the Opioid Dependence. Insomnia is common, especially during withdrawal. Antisocial Personality Disorder is much more common in individuals with Opioid Dependence than in the general population. Posttraumatic Stress Disorder is also seen with increased frequency. A history of Conduct Disorder in childhood or adolescence has been identified as a significant risk factor for Substance-Related Disorders, especially Opioid Dependence.
Associated laboratory findings.
Routine urine toxicology tests are often positive for opioid drugs in individuals with Opioid Dependence. Urine tests remain positive for most opioids for 12-36 hours after administration. Longer-acting opioids (e.g., methadone and LAAM) can be identified in urine for several days. Fentanyl is not detected by standard urine tests but can be identified by more specialized procedures. Laboratory evidence of the presence of other substances (e.g., cocaine, marijuana, alcohol, amphetamines, benzodiazepines) is common. Screening tests for hepatitis A, B, and C are positive in as many as 80%-90% of intravenous users, either for hepatitis antigen (signifying active infection) or hepatitis antibody (signifying past infection). Mildly elevated liver function tests are common, either as a result of resolving hepatitis or from toxic injury to the liver due to contaminants that have been mixed with the injected opioid. Subtle changes in cortisol secretion patterns and body temperature regulation have been observed for up to 6 months following opioid detoxification.
Associated physical examination findings and general medical conditions.
Acute and chronic opioid use are associated with a lack of secretions, causing dry mouth and nose, slowing of gastrointestinal activity, and constipation. Visual acuity may be impaired as a result of pupillary constriction. In individuals who use opioids intravenously, sclerosed veins ("tracks") and puncture marks on the lower portions of the upper extremities are common. Veins sometimes become so badly sclerosed that peripheral edema develops and individuals switch to veins in the legs, neck, or groin. When these veins become unusable or otherwise unavailable, individuals often inject directly into their subcutaneous tissue ("skin-popping"), resulting in cellulitis, abscesses, and circular-appearing scars from healed skin lesions. Tetanus and Clostridium botulinum infections are relatively rare but extremely serious consequences of injecting opioids, especially with contaminated needles. Infections may also occur in other organs and include bacterial endocarditis, hepatitis, and human immunodeficiency virus (HIV) infection. Tuberculosis is a particularly serious problem among individuals who use drugs intravenously, especially those dependent on heroin. Infection with the tubercle bacillus is usually asymptomatic and evident only by the presence of a positive tuberculin skin test. However, many cases of active tuberculosis have been found, especially among those who are infected with HIV. These individuals often have a newly acquired infection, but also are likely to experience reactivation of a prior infection due to impaired immune function. Persons who sniff heroin or other opioids ("snorting") often develop irritation of the nasal mucosa, sometimes accompanied by perforation of the nasal septum. Difficulties in sexual functioning are common. Males often experience erectile dysfunction during intoxication or chronic use. Females commonly have disturbances of reproductive function and irregular menses.
The incidence of HIV infection is high among individuals who use intravenous drugs, a large proportion of whom are individuals with Opioid Dependence. HIV infection rates have been reported to be as high as 60% among persons dependent on heroin in some areas of the United States.
In addition to infections such as cellulitis, hepatitis, HIV, tuberculosis, and endocarditis, Opioid Dependence is associated with a death rate as high as 1.5%-2% per year. Death most often results from overdose, accidents, injuries, AIDS, or other general medical complications. Accidents and injuries due to violence that is associated with buying or selling drugs are common. In some areas, violence accounts for more opioid-related deaths than overdose or HIV infection. Physiological dependence on opioids may occur in about half of the infants born to females with Opioid Dependence; this can produce a severe withdrawal syndrome requiring medical treatment. Although low birth weight is also seen in children of mothers with Opioid Dependence, it is usually not marked and is generally not associated with serious adverse consequences.
Specific Culture, Age, and Gender Features
Since the 1920s, in the United States, members of minority groups living in economically deprived areas have been overrepresented among persons with Opioid Dependence. However, in the late 1800s and early 1900s, Opioid Dependence was seen more often among white middle-class individuals, especially women, suggesting that differences in use reflect the availability of opioid drugs and other social factors. Medical personnel who have ready access to opioids may have an increased risk for Opioid Abuse and Dependence.
Increasing age is associated with a decrease in prevalence. This tendency for Dependence to remit generally begins after age 40 years and has been called "maturing out." However, many persons have remained opioid dependent for 50 years or longer. Males are more commonly affected, with the male-to-female ratio typically being 1.5:1 for opioids other than heroin (i.e., available by prescription) and 3:1 for heroin.
Prevalence
A 1996 national survey of drug use reported that 6.7% of men and 4.5% of women in the United States acknowledged ever using an analgesic drug in a manner other than that for which it was prescribed, including 2% who had used these drugs in the prior year and approximately 1% who had taken these drugs in the prior month. The medically inappropriate use of analgesics had its highest lifetime prevalence among individuals between ages 18 and 25 (9%), with 5% in this age group acknowledging ever having taken the drug in the prior year, and 2% acknowledging ever having taken the drug in the prior month. The lifetime prevalence for heroin use was around 1%, with 0.2% having taken the drug during the prior year. A 1997 survey of drug use among high school students reported that around 2% of high school seniors had ever taken heroin and 10% acknowledged the inappropriate use of other "analgesics." These lifetime heroin rates for high school seniors are higher than the 1990 and 1994 rates (1.3% and 1.2%, respectively) and represent the highest figures since the 1975 rate of over 2%.
Because the surveys assessed patterns of use rather than disorders, it is not known how many of those who used analgesics or heroin had symptoms that met criteria for Dependence or Abuse. A community study conducted in the United States from 1980 to 1985 that used the more narrowly defined DSM-III criteria found that 0.7% of the adult population had Opioid Dependence or Abuse at some time in their lives. Among those individuals with Dependence or Abuse, 18% reported use in the last month and 42% reported having had a problem with opioids in the last year.
Course
Opioid Dependence can begin at any age, but problems associated with opioid use are most commonly first observed in the late teens or early 20s. Once Dependence develops, it usually continues over a period of many years, even though brief periods of abstinence are frequent. Relapse following abstinence is common. Although relapses do occur, and while some long-term mortality rates have been reported to be as high as 2% per year, about 20%-30% of individuals with Opioid Dependence achieve long-term abstinence. An exception to the chronic course of Opioid Dependence was observed in service personnel who became dependent on opioids in Vietnam. On their return to the United States, less than 10% of those who had been dependent on opioids relapsed, although they experienced increased rates of Alcohol or Amphetamine Dependence. Few data are available on the course of Opioid Abuse.
Familial Pattern
The family members of individuals with Opioid Dependence are likely to have higher levels of psychopathology, especially an increased incidence of other Substance-Related Disorders and Antisocial Personality Disorder.
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Opioid-Induced Disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders (e.g., Dysthymic Disorder versus Opioid-Induced Mood Disorder, With Depressive Features, With Onset During Intoxication). See p. 210 for a discussion of this differential diagnosis. Opioids are less likely to produce symptoms of mental disturbance than are most other drugs of abuse. Alcohol Intoxication and Sedative, Hypnotic, or Anxiolytic Intoxication can cause a clinical picture that resembles Opioid Intoxication. A diagnosis of Alcohol or Sedative, Hypnotic, or Anxiolytic Intoxication can usually be made based on the absence of pupillary constriction or the lack of a response to a naloxone challenge. In some cases, intoxication may be due both to opioids and to alcohol or other sedatives. In these cases, the naloxone challenge will not reverse all of the sedative effects. The anxiety and restlessness associated with Opioid Withdrawal resemble symptoms seen in Sedative, Hypnotic, or Anxiolytic Withdrawal. However, Opioid Withdrawal is also accompanied by rhinorrhea, lacrimation, and pupillary dilation, which are not seen in sedative-type withdrawal. Dilated pupils are also seen in Hallucinogen Intoxication, Amphetamine Intoxication, and Cocaine Intoxication. However, other signs or symptoms of Opioid Withdrawal such as nausea, vomiting, diarrhea, abdominal cramps, rhinorrhea, or lacrimation are not present. Opioid Intoxication and Opioid Withdrawal are distinguished from the other Opioid-Induced Disorders (e.g., Opioid-Induced Mood Disorder, With Onset During Intoxication) because the symptoms in these latter disorders are in excess of those usually associated with Opioid Intoxication or Opioid Withdrawal and are severe enough to warrant independent clinical attention.