Should Prescription Opioid Use Disorder Diagnostic Criteria Consider Patient Motivations?

Pain-adjusted measures for evaluating prescription opioid use disorder were found to be reliable and more valid than standard DSM-5 criteria.
The authors of a study published in the American Journal of Psychiatry advocated for adapting prescription opioid use disorder (POUD) diagnostic criteria to differentiate between therapeutic and nontherapeutic intent.

Patients (N=606) were recruited from 2 inpatient substance treatment centers (n=258) and 4 outpatient pain clinics (n=348) located in both urban and suburban areas in New York to participate in the study ( Identifier: NCT02660619). Eligibility criteria included participant age of 18 years of age and older and having had received an at least 30-day supply of opioids for the treatment of chronic pain. Participants were evaluated for POUD using standard criteria (ie, withdrawal and tolerance) and pain-adjusted measures (ie, behavioral or subjective criteria to assess motive). Evaluations were conducted using the computer-assisted Psychiatric Research Interview for Substance and Mental Disorders, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) opioid version (PRISM-5-OP), with 3 criteria sets applied:  completely unadjusted; DSM-5, and pain adjusted.  A subset of participants (n=206) underwent additional testing an average of 7.2 (range, 0-19) days after the initial evaluation. Potential reliability and validity of the pain-adjusted POUD assessment were evaluated.

Approximately one-half of the study population was aged 50 years and older and unmarried, and the cohort had an equal number of men and women. Patients receiving treatment for pain in outpatient pain clinics were more often older, women, and married.

In participants meeting the threshold of at least 2 criteria, the prevalence of a diagnosis of POUD was 44.4% for the DSM-5 criteria and 30.4% for the pain-adjusted criteria. In participants meeting the threshold of at least 4 criteria, the prevalence of a POUD diagnosis was 29.5% for the DSM-05 criteria and 25.3% for the pain-adjusted criteria.

Stratified by treatment for substance use vs pain therapy, more participants undergoing treatment for substance use met the DSM-5 criteria for a diagnosis of POUD (61.6% vs 31.6%) when the pain-adjusted criteria were used. Using the at least 2 criteria threshold, far fewer patients (9.8%) receiving pain therapy met the pain-adjusted criteria for a diagnosis of POUD compared with 58.1% of patients undergoing treatment for substance use. Similar trends were observed for the at least 4 criteria threshold.

In the retest samples, the DSM-5 (κ, 0.49) and pain-adjusted (κ, 0.47) evaluations were similarly reliable among the cohort undergoing inpatient substance treatment. For those patients in the outpatient pain cohort, the pain-adjusted criteria were more reliable (κ, 0.80) than the DSM-5 criteria (κ, 0.64) on subsequent testing.

Compared between the criteria, the pain-adjusted evaluation was favored for the dimensional POUD measures of substance treatment, family history of any drug use disorder, personal history of other substance use disorder, antisocial personality disorder, internalizing disorders, tampering, sensation-seeking, and impulsivity (ratio of mean ratios range, 1.22-2.31).

For the POUD binary diagnostic measures, the pain-adjusted diagnostic criteria were associated with all 10 validators at the at least 2 criteria threshold and with 9 of the 10 validators at the at least 4 criteria threshold compared with 5 validators at the at least 2 criteria threshold and 7 validators at the at least 4 criteria thresholds for the DSM-5 diagnostic criteria.

A major limitation of the POUD diagnostic interviews is that patient responses may be affected by stigma or social desirability bias.

The study authors concluded, “We found that the PRISM-5-OP measures of pain-adjusted POUD measures were reliable and more valid than standard DSM-5 concepts of substance use disorder. However, many external validators were associated with DSM-5 as well as pain-adjusted POUD measures. Studies should report both sets of results and further investigate differences between pain-adjusted and DSM-5 POUD and their consequences.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Hasin DS, Shmulewitz D, Stohl M, et al. Diagnosing prescription opioid use disorder in patients using prescribed opioids for chronic pain. Am J Psychiatry. Published online June 15, 2022.  doi:10.1176/appi.ajp.21070721