Challenging the Utility of DSM-5 Opioid Use Disorder Criteria for Diagnosing Problematic Prescription Opioid Use: Next Steps

When opioid therapy for chronic pain was first promulgated in the 1980s and 90s, it was thought that addiction would be rare, would occur only in high-risk individuals, and should not interfere with the continued treatment with opioids for patients without opioid use disorder. DSM-5 OUD criteria were used as a means of separating out patients who had developed disordered opioid use from those who had not. This compartmentalization encouraged prescribers to refer those patients diagnosed with an OUD to addiction treatment, but to continue the focus on treating pain for others. But this binary approach failed to recognize that when a patient with chronic pain is treated with long-term opioid therapy, opioid need for pain may be hard to distinguish from withdrawal. This arises from the interaction of pain relief with opioid reward, which changes the motivations for continued opioid use in ways not always obvious to patients or prescribers. In this article, we propose that a syndrome of dependence develops during continued opioid pain treatment that should be considered distinct from POUD. Recognition of a prescription opioid dependence syndrome (PODS) allows for a more nuanced approach to the treatment of failed opioid pain treatment, especially in cases where neither continued high-dose opioid pain treatment nor evidence-based addiction treatment is a good option. We believe that recognition of this syndrome is a necessary first step towards improving treatment for the millions of people struggling with pain and opioid use.