How do you diagnose opioid use disorder in a patient with moderately severe withdrawal symptoms?

Diagnosing Opioid Use Disorder in Patients with Moderately Severe Withdrawal

Diagnose opioid use disorder (OUD) by applying DSM-5 criteria through clinical interview, and simultaneously assess withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS), where a score of 25-36 indicates moderately severe withdrawal requiring immediate buprenorphine treatment. 1

Diagnostic Approach for OUD

Apply DSM-5 Diagnostic Criteria

• Administer the OUD checklist from DSM-5 to identify the presence of opioid use disorder, which requires at least 2 of 11 criteria within a 12-month period 1
• Key diagnostic features include: unsuccessful efforts to reduce or control use, use resulting in social problems, failure to fulfill major role obligations, continued use despite physical or psychological problems, tolerance, and withdrawal 1
• Critical caveat: Many DSM-5 criteria for OUD can overlap with symptoms of chronic pain in patients receiving long-term opioid therapy, risking false-positive diagnoses 1
• If diagnostic uncertainty exists, consultation with an addiction specialist is essential before proceeding with treatment decisions 1

Assess Withdrawal Severity with COWS

Use the Clinical Opiate Withdrawal Scale (COWS) to quantify withdrawal severity 1, 2:

• COWS scoring ranges: 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), >36 (severe withdrawal) 1, 2
• The COWS is an 11-item clinician-administered scale assessing: resting pulse rate, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety, and piloerection 1
• For moderately severe withdrawal (COWS 25-36): This indicates significant physiologic dependence requiring pharmacologic intervention 1, 2

Distinguish OUD from Physical Dependence

Physical dependence alone does not equal OUD 1:

• Physical dependence manifests as withdrawal symptoms upon opioid discontinuation and is an expected physiologic response after extended opioid exposure 1
• Physical dependence typically resolves within 3-7 days after discontinuation, whereas OUD is a chronic relapsing disorder requiring long-term management 1, 3
• OUD involves compulsive use despite harm, unsuccessful control attempts, and continued use causing social/occupational dysfunction—not merely the presence of tolerance and withdrawal 1

Complementary Diagnostic Tools

Prescription Drug Monitoring Program (PDMP)

• Review PDMP data to identify concurrent opioid prescriptions from multiple providers, which increases overdose risk and may suggest problematic use 1
• PDMP findings of multiple prescribers warrant discussion with the patient about safety concerns, not automatic dismissal from care 1
• Calculate total morphine milligram equivalents (MME) per day from all prescriptions to assess overdose risk 1

Urine Drug Testing

• Urine drug testing before initiating treatment can identify undisclosed opioid use or other substances 1
• Testing should assess for prescribed medications, other controlled substances, and illicit drugs 1
• Important limitation: Urine toxicology alone is not reliable for diagnosing OUD and must be interpreted within clinical context 4

Validated Screening Instruments

• The Screen of Drug Use (SoDU) demonstrates 100% sensitivity and 86.3% specificity for detecting OUD in primary care settings 4
• The Opioid Risk Tool has inconsistent accuracy for predicting opioid misuse 1

Management Based on Diagnosis

If OUD is Confirmed with Moderately Severe Withdrawal

Initiate medication-assisted treatment (MAT) with buprenorphine/naloxone immediately 1:

• Buprenorphine is indicated for COWS scores >8 (moderate to severe withdrawal) 2
• Target dose: 16 mg sublingual buprenorphine for most patients, with reassessment 30-60 minutes after initial dose 2
• Buprenorphine/naloxone is preferred over buprenorphine alone due to abuse-deterrent properties 1
• Evidence: Methadone and buprenorphine have the strongest evidence for OUD treatment efficacy and mortality reduction 5, 3, 6

If Physical Dependence Without OUD

• Consider very slow opioid taper (10% per month or slower) rather than abrupt discontinuation 1
• Address comorbid depression, anxiety, and insomnia before and during taper 1
• Provide clonidine or other adjuvant medications to manage withdrawal symptoms during taper 1

Critical Safety Measures

• Provide naloxone for overdose prevention education and take-home kit 2
• Arrange follow-up for MAT continuation, as this demonstrates better outcomes than referral alone 2
• Never dismiss patients from practice based on diagnostic findings, as this represents patient abandonment and increases overdose risk 1