Identifying opioid misuse and opioid use disorder

Early identification of an opioid problem can help stop the progression from misuse of opioids to the development of an opioid use disorder. In short, early identification helps prevent a poor prognosis. And when it comes to substance use, clinicians need to ask; people may not disclose substance use without the clinician providing a specific and safe opportunity to discuss this issue. Accordingly, screening for opioid (and other drug) misuse should be included as standard practice in any clinical setting.

All patients should be asked about current or past prescriptions for opioids (as well as other medications with misuse potential, such as benzodiazepines). This provides an opportunity to educate patients about safe medication management and disposal.

A simple universal screening question that can be used in any clinical setting is: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons (e.g., because of the experience or feeling it caused)?”¹ If the answer to this screening question is yes, detailed screening is indicated.

Three types of answers indicate concerning drug use patterns:

• use of the medication for the express purpose of getting high or changing how one feels
• use of more medication than prescribed or for a longer time than prescribed
• purchasing the medication illegally or via “doctor shopping” (going to multiple doctors to renew or gain additional prescriptions)

The National Institute on Drug Abuse Modified ASSIST Screening Toolopens in new window is a free, readily available, brief, and useful detailed screening. This web-based screening tool assesses for problematic alcohol, tobacco, and prescription and illicit drug use. Results are stratified into risk categories, with corresponding clinical guidance and downloadable materials for referral and treatment.

Opioid misuse is highly stigmatized, which can be a barrier to reporting. Much like the assessment of any psychiatric disorder, ancillary information from other data sources can be helpful for identifying problematic opioid use. Multimethod assessment will minimize the weaknesses of any one approach. Family involvement is an obvious option; yet family involvement can be complex, as opioid use progresses toward a disorder due to issues such as stigma and interpersonal conflict. Involvement of family members in assessment needs to be carefully considered in collaboration with the patient.

Sometimes the request for assessment comes from a concerned family member, either directly or indirectly, with such statements as:

• “I fear my son is using drugs.”
• “My father told me his pain pills were missing after my family visited his house.”
• “I found some pills hidden, and I think they are oxycodone.”

The most important response to such queries is to treat them seriously and to communicate the importance of early detection. Your job is not to make the concerned family member into a detective but to share relevant information on opioids and their dangers. Furthermore, clinicians are in an excellent position to model and role play how a patient can have a conversation with the family member about opioid use.

Family members can also benefit from talking with others who are impacted by opioid use disorder in their family. Family members may find that attending mutual help support groups can improve mental health, quality of life, and coping with addiction, as well as reduce self-blame and stress.

Mutual help support groups for family members include:

• Nar-Anon Family Groupsopens in new window
• SMART Recovery Family and Friends Toolboxopens in new window
• Learn to Copeopens in new window

Objective screening (drug assays) is another method for gaining information on drug use patterns. Metabolites of substances can be detected in fluids such as urine, blood, and saliva. In addition to hospital- or clinic-based facilities for drug screens, some simple kits for drug screens can be purchased at drugstores (allowing private practice clinicians to arrange for simple testing, if needed). However, each method varies in its reliability and effectiveness. Of critical importance when interpreting drug assay data is to consider:

• The detectable time frame of the substance (e.g., for some opioids, the window of detection can be as brief as 3 days).
• The range of substances assessed—a thorough opioid panel will include separate tests for opiates, oxycodone, methadone, buprenorphine, and fentanyl.
• The possibility of test manipulation, such as use of someone else’s urine.

Use of occasional objective screening, in addition to providing direct evidence of drug use, may also have the beneficial effect of enhancing the veracity of self-report.

Clinicians in practice are on the front lines of early detection of opioid use patterns. This detection requires an active (asking) rather than a passive (waiting to be told) assessment style. The pathway to early detection may be through the patient directly or through a concerned family member. Either way—early detection means a better prognosis.