In 2003, an estimated 21.6 million Americans were classified as having a substance use disorder (9.1% of the population ages 12 and older).¹

The nature of medicine gives physicians and nurses "the best opportunity" to intervene and interrupt the progression of substance abuse.² However, most medical schools devote only a few hours to the topic.² According to surveys conducted in 2000 by Columbia University, 94% of primary care physicians failed to diagnose substance abuse in patients who displayed "classic symptoms."²

Screening for opioid dependence is similar to screening for other chronic medical conditions: Disease symptoms and risk factors are detectable through a routine patient interview or physical examination.

Several of the physical and behavioral symptoms associated with opioid use are itemized in the lists below (these lists are not intended as diagnostic tools):

Physical Signs of Opioid Intoxication 
Physical Signs of Opioid Overdose
Physical Signs of Opioid Misuse
Psychosocial Signs of Opioid Dependence
DSM-IV Criteria for Substance Dependence

Physicians who believe a patient's symptoms warrant further screening are encouraged to do so (see Encouraging Patients to Open Up and General Guidelines for Screening Questions for techniques to help facilitate more effective patient communication).

Alternatively, if a patient's needs (in addition to possible dependence) exceed what can reasonably be addressed through your practice, you may want to consider referring that patient to another DATA 2000 certified physician.

Additional screening consideration: Laboratory tests (ie, blood or urine tests) for opioids are generally not recommended as routine screening tools, because in the absence of a comprehensive substance use assessment, positive results are still considered insufficient basis for a diagnosis of dependence.^3,4

Laboratory tests are, however, commonly used to confirm a diagnosis of opioid dependence.³

Additional Resources

• Substance use assessment and diagnosing opioid dependence are explored in more depth under 1st Visit (Intake) in the Patient Management section of the Practice Management Tool Kit
• Steps for becoming DATA 2000 certified
• Frequently asked questions about the certification process
• Literature for physicians and practices treating opioid dependence

Physical Signs of Opioid Intoxication³

• Pupillary constriction
• Sedation, drowsiness
• "Nodding" or intermittent dozing
• Slurred speech
• Mood normal to euphoric
• Memory impairment
• Lowered blood pressure or pulse rate
• Shallow or slow respiration⁵

Physical Signs of Opioid Overdose³

• Unconsciousness
• Pinpoint pupils
• Very shallow, slow respirations (below 10 per minute)
• Very slow pulse rate (below 40 per minute)
• Overdose triad: apnea, coma, pinpoint pupils (with terminal anoxia: fixed and dilated pupils)

Physical Signs of Opioid Misuse
Opioid misuse often accompanies opioid dependence. Consider further screening in patients with evidence of any of the following (assuming no other cause for symptoms is found, eg, medical condition or medication side effect)⁴:

• Pupillary constriction
• Constipation
• Nausea
• Sleepiness
• Euphoria
• Track marks or scars
• Skin necrosis
• Allergic reactions
• Tourniquet pigmentation
• Abscess, cellulitis, or dermatitis at injection sites
• Atrophied or perforated nasal septum⁶
• Sexually and needle-transmitted diseases, including HIV, hepatitis, and endocarditis⁶

Psychosocial Signs of Opioid Dependence
There are no known psychosocial signs of opioid dependence per se, but certain patterns are frequently observed among individuals dependent on opioids. Consider further screening in patients with evidence of any of the following⁴:

• Mood instability
• Agitation
• Anxiety
• Anger
• Irritability
• Depression
• Mood swings
• Family problems
• Marital issues
• Abuse or violence
• Children's behavioral problems
• Signs of anxiety or depression in family members
• Significant social changes
• Loss of long-standing friendships
• Social isolation
• Loss of interest in regular activities
• Spending time with other drug abusers
• Work or school problems
• Missed days
• Poor performance
• Frequent job changes or relocations
• Legal problems
• Arrests
• DUIs
• Theft
• Drug dealing
• Financial problems
• Large recent debt
• Borrowing money from friends or relatives
• Selling possessions

DSM-IV Criteria for Substance Dependence
Once a thorough patient assessment has been performed, a formal diagnosis of opioid dependence can be made. A substance dependence diagnosis, according to current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic schema, is based on clusters of behaviors and physiologic effects occurring within a specific time frame.⁷ A diagnosis of dependence always takes precedence over that of abuse, ie, a diagnosis of abuse is made only if the DSM-IV criteria for dependence have never been met.⁷

DEPENDENCE	ABUSE
3 or more in a 12-month period	1 or more in a 12-month period (Symptoms must never have met criteria for dependence)
Tolerance (marked increase in amount; marked decrease in effect)	Recurrent use resulting in failure to fulfill major role obligation at work, home, or school
Characteristic withdrawal symptoms; substance taken to relieve withdrawal	Recurrent use in physically hazardous situations
Substance taken in larger amount and for longer period than intended	Recurrent substance-related legal problems
Persistent desire or repeated unsuccessful attempt to quit	Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance
Much time/activity to obtain, use, recover
Important social, occupational, or recreational activities given up or reduced
Use continues despite knowledge of adverse consequences (eg, failure to fulfill role obligation, use when physically hazardous)

In using the DSM-IV criteria, one should specify whether substance dependence is with physiologic dependence (ie, there is evidence of tolerance or withdrawal) or without physiologic dependence (ie, no evidence of tolerance or withdrawal). In addition, patients may be variously classified as currently manifesting a pattern of abuse or dependence or as in remission. Those in remission can be divided into 4 subtypes—full, early partial, sustained, and sustained partial—on the basis of whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (eg, methadone maintenance) or for those living in a controlled drug-free environment.