DILLA UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH

SCIENCE
DEPARTMENT OF PSYCHIATRY
Opioid Use and Related Disorders
Instructor:- Kiber. T ( MSc in
03/07/2025
ICCMH) 1
 Outline
 Definitions and overview
 Epidemiology
 Etiology/pathophysiology
 Course
 Diagnosis
 Severity/specifiers
 Withdrawal/intoxication
 Other mental health disorders due to the substance
 Treatment
 Reference

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 Objectives
 After this session you will be able to:-
 Define what opioid means.
 Describe the prevalence and etiology of opioid related
disorder.
 Clearly state the course and prognosis of opioid related
disorder.
 List the diagnosis criteria of opioid related disorder
including intoxication, withdrawal and opioid induced
mental disorder.
 Apply the management principle of opioid related
disorder.
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03/07/2025 4
 Definitions and overview

 Opioid is a class of psychoactive compounds, that are related

to opiates (all natural opioids).
 Refers to all natural, semi-synthetic, and synthetic opioid
drugs.
 It found as natural products in the opium poppy plant.
 Opioids are among the oldest known drugs worldwide.
 Opioids have been used for analgesic and other medicinal
purposes for thousands of years, but they also have a long
history of misuse for their psychoactive effects.
 Opioids can be used medically for pain relief, but are also
commonly misused by means of nonprescribed use of
pharmacological opioids or illicitly obtained heroin.

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Chemical structures of common medicinal and illicit opioids.

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 CONT…
 Continued opioid misuse can result disturbances in
 Mood
 Behavior
 Cognition that can mimic other psychiatric disorders.
 In addition to controlling pain, opioids can make some
people feel relaxed, happy or “high,” and can be addictive.
 Additional side effects can include
 Slowed breathing
 Constipation
 Nausea
 Confusion
 Drowsiness.
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 Neurobiology of Opioid Use Disorders
 A variety of opioid compounds exist.
 Morphine, codeine, and oxycodone are commonly prescribed
medications for pain relief but can also be diverted for nonmedical
use.
 Heroin or diacetylmorphine is the opioid that is most abused by
injection; common street names include dope, horse, smack, and tar.
 The opioid receptors are distributed widely in the brain, the spinal
cord, and digestive tract.
 There are four currently known types of opioid receptors,
 Delta (δ)-opioid receptors with analgesia.
 Kappa (κ) -opioid receptors with analgesia, diuresis, and sedation.
 Mu (μ) -opioid receptors are involved in the regulation and
mediation of analgesia, respiratory depression, constipation, and drug
dependence.
 Nociceptin(NOP)- receptor
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 CONT…
 The endogenous opioids (endorphins, the dynorphins, and the
enkephalins) have significant interactions with other neuronal
systems, such as the dopaminergic and noradrenergic
neurotransmitter systems.
 Several types of data indicate that the addictive rewarding
properties of opioids are mediated through activation of the
ventral tegmental area dopaminergic neurons that project to
the cerebral cortex and the limbic system.

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 Epidemiology
 The 12-month prevalence of opioid use disorder is
approximately 0.37% among adults in the community.
 Rates are higher in males than in females (0.49% vs. 0.26%),
with the M:F ratio typically being 1.5:1 for opioids but for
heroin 3:1.
 The prevalence decreases with age, with the prevalence highest
0.82% among adults aged 29 years or younger and decreasing
to 0.09% among adults aged 65 years and older.

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 Etiology/ pathophysiology

1. Psychosocial Factors
 Genetic and neural circuits eventually contribute to
addiction behavior through their interaction with
complex environmental and psychosocial factors.
 Social attitudes
 Peer pressure
 Individual temperament
 Drug availability are all determinants of the emergence of
problematic opioid use.

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 Etiology/pathophysiology
2. Biological and Genetic Factors
 Monozygotic twins are more likely than dizygotic twins to be
concordant for opioid dependence.
 Genetically determined hypoactivity of the opiate system that
may be caused by too few, or less-sensitive opioid receptors, by
release of too little endogenous opioid, or high opioid
antagonist.
 A biological predisposition associated with abnormal
functioning in either the dopaminergic or the noradrenergic
neurotransmitter system.

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 Etiology/Pathophysiology…
3. Psychodynamic theory
 Addicted to narcotics has been described in terms of
libidinal fixation, with regression to pregenital and oral
stage.
 libidinal fixation is a psychological concept that occurs
when a person's libido remains focused on a particular stage
of development, instead of moving on to the next stage.
 Ego pathology, is considered to indicate profound
developmental disturbances.

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 Course and prognosis

• Most commonly, affected individuals will experience a chronic

and recurring course of the illness.
• Once opioid use disorder develops, it usually continues over a
period of many years, even though brief periods of abstinence
are frequent.
• In treated populations, relapse following abstinence is
common.

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 Course and prognosis…
• Mortality rates may be as high as 2% per year, about
20%-30% of individuals with opioid use disorder achieve
long-term abstinence.
• Sustaining ongoing treatment and monitoring, longer
lengths of stay in treatment, and self-motivation have
been identified as the most important reasons for long-
term recovery.
• Other protective factors include
 Religion
 Spirituality
 Employment
 Family.
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 Course and prognosis…

• Positive outcomes, such as greater involvement in

prosocial activities (e.g., employment) and improved
mental health, are both effects of long-term recovery.
• Predictors of treatment outcome legitimate work, low
crime, less drug use, family relationships, and
psychological adjustment are favorable indicators for
good long-term prognosis.

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 Course and prognosis…

• Severity of comorbid psychiatric conditions at the beginning

of treatment is usually a bad prognosis.
• Increasing age is associated with a decrease in prevalence
because of early mortality and the remission of symptoms
after age 40 years.

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 DIAGNOSIS AND CLINICAL FEATURES

 DSM-5 divides Opioid Use and related disorders into five

main diagnoses:
1. Opioid use disorder
2. Opioid intoxication
3. Opioid withdrawal
4. Opioid-Induced Mental Disorders.
5. Unspecified opioid-related disorder

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 1. Opioid Use Disorder
 This disorder primarily reflects a pattern of compulsive,
prolonged self administration of opioid substances that have
no legitimate medical purpose or at doses greatly exceeding
the amount needed for a medical condition, with continuing
use of opioids despite significant substance related problems.
 Individuals with opioid use disorder tend to develop such
regular patterns of compulsive drug use that daily activities
are planned around obtaining and administering opioids.

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 CONT…

 Opioids are usually purchased on the illegal market but may

also be obtained from physicians by falsifying or exaggerating
general medical problems or by receiving simultaneous
prescriptions from several physicians.
 Health care professionals with opioid use disorder will often
obtain opioids by writing prescriptions for themselves or by
diverting opioids that have been prescribed for patients or
from pharmacy supplies.

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 DSM-5
A. Problematic pattern of opioid use leading to clinically
significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:
1. Opioids are often taken in larger amounts or over a longer
period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut
down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain
the opioid, use the opioid, or recover from its effects.

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 CONT…

4. Craving, or a strong desire or urge to use opioids

5. Recurrent opioid use resulting in a failure to fulfill major role
obligations at work, school, or home.
6. Continued opioid use despite having persistent or recurrent
social or interpersonal problems.
7. Important social, occupational, or recreational activities are
given up or reduced because of opioid use.

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 CONT…

8. Recurrent opioid use in situations in which is physically hazardous.

9. Continued opioid use despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have
been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of opioids to achieve
intoxication or desired effect
b. A markedly diminished effect with continued use of the same
amount of an opioid.

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 CONT…

11. Withdrawal, as manifested by either of the following:

a. The characteristic opioid withdrawal syndrome (refer to
Criteria A and B of the criteria set for opioid withdrawal.
b. Opioids (or a closely related substance) are taken to relieve
or avoid withdrawal symptoms.
Note: This criterion is not considered to be met for those
individuals taking opioids solely under appropriate medical
supervision (criteria 10 and 11).

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 Severity/Specifiers

1. The duration of remission:

 In early remission: none of the criteria for opioid use
disorder have been met for at least 3 months but for less
than 12 months (exception Criterion A4, Craving).
 In sustained remission: none of the criteria for opioid use
disorder have been met at any time during a period of 12
months or longer (exception Criterion A4, Craving).

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 Severity/Specifiers…
2. Whether the individual is on maintenance therapy
 This additional specifier is used if the individual is taking a
prescribed agonist medication such as methadone or
buprenorphine and none of the criteria for opioid use disorder
have been met for that class of medication (except tolerance
and withdrawal from, the agonist).
• On maintenance therapy, specifier applies as a further specifier
of remission if the individual is both in remission and receiving
maintenance therapy.

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 Severity/Specifiers…
3. Whether the individual is in a controlled environment:
 In a controlled environment: This additional specifier is used if
the individual is in an environment where access to opioids is
restricted.
• In a controlled environment applies as a further specifier of
remission if the individual is both in remission and in a
controlled environment.

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 Severity/Specifiers…

Specify current severity

• Mild: Presence of 2 -3 symptoms.
• Moderate: Presence of 4-5 symptoms.
• Severe: Presence of 6 or more symptoms.

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 2. Opioid Intoxication

A. Recent use of an opioid.

B. Clinically significant problematic behavioral or psychological
changes (e.g., initial euphoria followed by apathy, dysphoria,
psychomotor agitation or retardation, impaired judgment)
that developed during, or shortly after, opioid use.

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 Intoxication…
C. Pupillary constriction or pupillary dilation due to anoxia from
severe overdose and one or more of the following signs or
symptoms developing during, or shortly after, opioid use:
1. Drowsiness or coma.
2. Slurred speech.
3. Impairment in attention or memory.
D. The signs or symptoms are not attributable to another medical
condition and are not better explained by another mental
disorder.

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 Intoxication…

 Specify if:
 With perceptual disturbances:
 With use disorder, mild
 With use disorder, moderate or severe
 Without use disorder
 Without perceptual disturbances
With use disorder, mild
With use disorder, moderate or severe
Without use disorder

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 Differential Diagnosis
1. Other substance intoxication.
• Alcohol intoxication and sedative-hypnotic intoxication can
cause a clinical picture that resembles opioid intoxication.
• A diagnosis of alcohol or sedative-hypnotic intoxication can
usually be made based on the absence of pupillary
constriction or the lack of a response to a naloxone
challenge.

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 Differential Diagnosis…

2. Other opioid-related disorders.

 Opioid intoxication is distinguished from the other opioid-
induced disorders (e.g., opioid-induced depressive disorder,
with onset during intoxication) because the symptoms in the
latter disorders predominate in the clinical presentation and
meet full criteria for the relevant disorder.

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 3. Opioid Withdrawal

A. Presence of either of the following;

1. Cessation of (or reduction in) opioid use that has been
heavy and prolonged (i.e., several weeks or longer).
2. Administration of an opioid antagonist after a period of
opioid use.

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 Opioid Withdrawal…
B. Three (or more) of the following developing within minutes
to several days after Criterion A;
1. Dysphoric mood.
2. Nausea or vomiting.
3. Muscle aches.
4. Lacrimation or rhinorrhea.
5. Pupillary dilation, piloerection, or sweating.
6. Diarrhea.
7. Yawning.
8. Fever.
9. Insomnia.

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 Opioid Withdrawal…

C. The signs or symptoms in Criterion B cause clinically significant

distress or impairment in social, occupational, or other
important areas of functioning.
D. The signs or symptoms are not attributable to another medical
condition and are not better explained by another mental
disorder, including intoxication or withdrawal from substance.

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 Withdrawal…

• Standardized instruments have been developed to quantify

the severity of opioid withdrawal symptoms in clinical
practice.
• The Clinical Opioid Withdrawal Scale (COWS) is the most
used and utilizes resting pulse rate, sweating, restlessness,
pupil size, pain, rhinorrhea, GI symptoms tremor, yawning,
anxiety, and piloerection as anchor points.

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 Withdrawal…
• Morphine and Heroin. The morphine and heroin withdrawal
syndrome begins 6 to 8 hours after the last dose, usually
after a 1-to-2-week period of continuous use or after the
administration of a narcotic antagonist.
• Meperidine. The withdrawal syndrome of meperidine begins
quickly reaches peak in 8 to 12 hours and ends in 4 to5 days.
• Methadone. Methadone withdrawal usually begins 1 to 3
days after the last dose and ends in 10 to 14 days.

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 Differential Diagnosis
1. Other withdrawal disorders. The anxiety and restlessness
associated with opioid withdrawal resemble symptoms seen in
sedative hypnotic withdrawal.
2. Other substance intoxication. Dilated pupils are also seen in
hallucinogen and stimulant intoxication. But other signs or
symptoms of opioid withdrawal, such as nausea, vomiting,
diarrhea, abdominal cramps, rhinorrhea, and lacrimation, are
not present.

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 Differential Diagnosis…

3. Other opioid-induced disorders.

 Opioid withdrawal is distinguished from the other opioid-
induced disorders (e.g., opioid-induced depressive disorder,
with onset during withdrawal) because the symptoms in
these latter disorders are more than those usually associated
with opioid withdrawal and meet full criteria for the relevant
disorder.

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 4. Opioid-Induced Mental Disorders.
1. Opioid Intoxication Delirium is most likely to happen when
opioids are used in high doses, are mixed with other
psychoactive compounds, or are used by a person with
preexisting brain damage or a central nervous system (CNS)
disorder (e.g., epilepsy).
2. Opioid-Induced Psychotic Disorder can begin during opioid
intoxication. Clinicians can specify whether hallucinations or
delusions are the predominant symptoms.

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 CONT…
3. Opioid-Induced Mood Disorder
 Can begin during opioid intoxication. Opioid-induced mood
disorder symptoms can have a manic, depressed, or mixed
nature, depending on a person’s response to opioids.
 A person coming to psychiatric attention with opioid induced
mood disorder usually has mixed symptoms, combining
irritability, expansiveness, and depression.
 Opioid induced mood disorder should not be diagnosed after
opioid withdrawal unless the severity of mood disturbance
exceeds what is normally encountered or persists for more
than a few weeks.

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 CONT…
4. Opioid-Induced Sleep Disorder and Opioid-Induced
Sexual Dysfunction.
 Opioid-induced sleep disorder and opioid-induced sexual
dysfunction are common, and both hypersomnia and
insomnia are common complaints of patients who either
have opioid use disorder or are maintained on opioids for
therapeutic purposes.
 Common sexual dysfunctions for chronic opioid users
include erectile dysfunction and orgasmic difficulties.

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 5. Unspecified Opioid-Related Disorder
 The DSM-5 includes diagnoses for other opioid related
disorders with symptoms of delirium, abnormal mood,
psychosis, abnormal sleep, and sexual dysfunction that
cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
predominate.
 But do not meet the full criteria for any specific opioid
related disorder.

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 Treatment

Overdose Treatment
• The patient should be ventilated mechanically.
 Naloxone ,is a specific opioid antagonist administered IV at
a slow rate initially about 0.8 mg per 70 kg of body weight.
• If no response to the initial dosage occurs, naloxone
administration may be repeated after intervals of a few
minutes because the duration of action is short than other
opioid.

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 Treating Opioid Withdrawal and Detoxification

 Methadone. is a synthetic opiod agonist narcotic that

substitutes for heroin. It replace their usual substance of
abuse; the drug suppresses withdrawal symptoms.
• 20 to 80 mg PO/day is sufficing to stabilize a patient,
maximum doses is 120 mg.
 Levomethadyl is an opioid agonist that suppresses opioid
withdrawal. It is no longer used because some patients
developed prolonged QT intervals associated with
potentially fatal arrhythmias.

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 Treating Opioid Withdrawal and
Detoxification…
 Buprenorphine is an opioid agonist approved for opioid
dependence treatment.
• Daily dose of 8 to 10 mg appears to reduce heroin use.
 Neonatal Withdrawal about three fourths of all infants born
to addicted mothers experience the withdrawal syndrome.
• Maintaining a pregnant woman with opioid dependence on
a low dose of methadone (10 to 40 mg daily) may be the
least hazardous course to follow.

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 Psychotherapy
• The entire range of psychotherapeutic modalities is
appropriate for treating opioid related disorders.
• Individual psychotherapy, behavioral therapy, cognitive-
behavioral therapy and support group may all prove
effective for specific patients.
• Social skills training should be particularly emphasized for
patients with few social skills.
• Family therapy is usually indicated when the patient lives
with family members.

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 Reference

1. Kaplan & Sadock’s comprehensive textbook of

psychiatyry,10th edition.
2. Synopsis of Kaplan & Sadok’s 11th edition.
3. DSM 5.

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