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  • Opioid use disorder (OUD) consists of intoxication and withdrawal from the substance for which there is no cure. Since 1999, the number of overdose deaths contributed to OUD has more than tripled. These deaths have involved opioid substances including prescription opioids (ie, natural opioids, semisynthetic opioids, and methadone), as well as heroin and synthetic opioids (ie, illicitly manufactured fentanyl).


  • The true etiology behind substance use disorders (SUD) is unknown. In general, it is felt that there needs to be a triad of the right patient, with the right genetic risk factors, being exposed to the right medication or substance in order for a SUD to occur.


  • Signs and symptoms of opioid intoxication include euphoria, dysphoria, slurred speech, miosis, apathy, sedation, and attention impairment. Signs and symptoms of withdrawal include lacrimation, mydriasis, piloerection, diaphoresis, diarrhea, yawning, muscle aches, and insomnia. Pinpoint pupils, decreased breathing, pulmonary edema, loss of consciousness, and death may occur with opioid intoxication.

  • The onset of withdrawal ranges from a few hours after stopping heroin to 3–5 days after stopping methadone. Duration of withdrawal ranges from 3–14 days. Occurrence of delirium suggests withdrawal from another drug (eg, alcohol).

  • Symptoms can be scored on the Clinical Opiate Withdrawal Symptoms (COWS) assessment tool to assess severity of opioid withdrawal.

  • Laboratory tests to obtain include a comprehensive metabolic panel to monitor serum electrolyte concentrations in the setting of significant vomiting or diarrhea; check liver function tests if using buprenorphine. Arterial blood gases, pulse oximetry, and capnography are useful to assess respiratory depression in opioid intoxication.


  • The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) defines SUD as “problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of eleven criteria occurring in the preceding 12-month period.”

  • These behaviors fall into the categories of: (1) impaired control, (2) social impairment, (3) risky use, and (4) pharmacological criteria, including tolerance and withdrawal, and are outlined in Table 69-1.

  • SUDs occur in a broad range of severity from mild (2–3 symptoms) to moderate (4–5 symptoms) to severe (6 or more symptoms).

  • DSM-5 does not separate the diagnoses of substance abuse and substance dependence. Criteria are provided for SUD, accompanied by criteria for intoxication, withdrawal, substance-induced disorders, and unspecified substance-related disorders in some cases.

  • Addiction: A primary chronic neurobiologic disease characterized by the inability to consistently abstain, impairment in behavioral control, craving, dysfunctional emotional response, and diminished recognition of significant problems with behaviors and interpersonal relationships.

  • Intoxication: Development of a substance-specific syndrome after recent ingestion and presence in the body of a substance; it is associated with maladaptive behavior during the waking state caused by effects of the substance on the central nervous system (CNS).

  • Physical dependence: A state of adaptation manifested by a ...

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