What is the most common behavior suggestive of an emerging opioid use disorder?

Most Common Behavior Suggestive of Emerging Opioid Use Disorder

The most common behavior suggestive of emerging opioid use disorder is requesting early refills or escalating dosages, which represents the most frequently observed aberrant behavior pattern that should prompt immediate reassessment of the treatment plan. 1

Understanding Aberrant Opioid-Related Behaviors

The term "aberrant opioid-related behaviors" encompasses patient behavior patterns that alert providers to reassess the risk-benefit ratio of opioid therapy. 1 These behaviors exist on a spectrum of severity and include:

Most Common Behaviors (in order of frequency):

• Requests for early refills or escalating dosages - the most frequently reported concerning behavior 1
• Taking more medication than prescribed - often the earliest manifestation of problematic use 1
• Unremitting focus during clinic encounters on obtaining controlled substance prescriptions or specific brand-name formulations 1
• Repeated reports of lost or stolen medications 1
• Having multiple prescribers ("doctor shopping") 1, 2

More Severe Behaviors (less common but higher risk):

• Prescription forgery 1
• Sale or diversion of prescriptions 1
• Using opioids to "get high" or altering route of administration (snorting, crushing, injecting, smoking) - these behaviors pose imminent risk for overdose or legal consequences 1

Critical Distinction: Pseudo-Addiction vs. True Addiction

A crucial pitfall is misinterpreting undertreated pain as addiction. 1 Some "drug-seeking" behaviors, particularly using or requesting more medication than prescribed, may simply reflect:

• Expected physical dependence and tolerance that develops with chronic opioid therapy 1
• Undertreated pain, termed "pseudo-addiction" 1

The key differentiating feature: Pseudo-addiction resolves with effective pain treatment, whereas true addiction is characterized by the four cardinal features: impaired control over drug use, compulsive use, continued use despite harm, and craving. 1

Prevalence Data

The prevalence of aberrant analgesic use behaviors varies significantly based on population and history:

• 9% in persons without substance use history 1
• 37% reported any aberrant opioid behavior within 90 days in high-risk populations 1
• 73% lifetime prevalence in urban indigent adults 1
• Carefully diagnosed addiction occurs in <8% of cases, while "misuse" and aberrant behaviors occur in 15-26% of cases 1

Clinical Recognition According to DSM-5

Addiction should be suspected when there is: 1

• Pronounced craving for the drug 1
• Obsessive preoccupation with obtaining opioids 1
• Inability to refrain from using despite attempts to stop 1
• Escalation of drug taking beyond prescribed amounts 1

Immediate Clinical Actions When Aberrant Behaviors Are Identified

When concerning behaviors emerge, providers should: 1

1. Avoid immediate discharge from practice - this violates the principle of nonabandonment and undermines the therapeutic relationship 1

2. Consider a broad differential diagnosis promptly: 1

   • Inadequate analgesia
   • Substance use disorder development
   • Development of tolerance to opioids
   • Opioid-induced hyperalgesia
   • Self-medication of psychiatric symptoms

3. Reevaluate the current treatment strategy using unexpected behaviors or urine drug test results in combination with other clinical data 1

4. Reassess the risk-benefit ratio of continuing opioid therapy 1

5. Consider referral for specialty addiction treatment when indicated, as recovery is an expectable result of comprehensive, continuing care 1

Common Pitfall: "Drug-Seeking" Terminology

The term "drug-seeking" is problematic because it conflates normal physiologic responses with addiction. 2 The FDA drug label notes that "drug-seeking" behavior is very common in persons with substance use disorders and includes emergency calls near end of office hours, refusal to undergo appropriate examination, repeated "loss" of prescriptions, tampering with prescriptions, and reluctance to provide prior medical records. 2 However, preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with inadequate pain control. 2

Risk Factors That Increase Likelihood of Aberrant Behaviors

Providers should be aware that certain factors increase risk of opioid misuse: 1

• Prior history of substance use disorder (including alcohol and tobacco) 1
• Younger age 1
• Family history of substance use disorders 1
• Childhood trauma, including sexual abuse 1
• Personal or family psychiatric history 1
• History of motor vehicle collisions (possible marker for driving under influence) 1