OFFICIAL ABP TOPIC: 

Recognize, evaluate, and manage opioid use disorder

BACKGROUND

Opioid use disorder (OUD) is a chronic, relapsing condition associated with significant morbidity and mortality among adolescents and young adults. Nearly 1 in 4 youth report some type of opioid use, including medical prescriptions, and earlier exposure increases the risk of developing OUD. Rising rates of overdose deaths emphasize the importance of early recognition, evaluation, and effective management by pediatricians.

EVALUATION OF OPIOID USE DISORDER

SCREENING TOOLS Validated tools include:

• CRAFFT: Assesses past-year substance use and associated risky behaviors. Brief and easy to administer.
• BSTAD: Screens for problematic use of tobacco, alcohol, and other drugs with a simple frequency-based format.
• S2BI: Triage tool that categorizes substance use risk as low, moderate, or high based on past-year frequency.

These tools are effective for adolescents because they are brief, non-confrontational, and help build rapport. Screening is especially important for high-risk groups, such as:

• Patients with hepatitis C or HIV
• Patients on long-term opioid therapy without functional improvement
• Patients presenting with endocarditis, skin abscesses, or osteomyelitis

DIAGNOSTIC CRITERIA FOR OUD

The DSM-5 criteria describe a problematic pattern of opioid use causing significant impairment or distress, including at least 2 of the following in a 12-month period:

• Larger amounts or longer duration of use than intended.
• Unsuccessful attempts to cut down or control use.
• Significant time spent obtaining, using, or recovering from opioids.
• Cravings or urges to use opioids.
• Failure to fulfill major obligations at work, school, or home because of opioid use.
• Important social or recreational activities given up or reduced because of opioids.
• Recurrent use in situations that are physically hazardous.
• Development of tolerance.
• Withdrawal symptoms when opioids are not continued.

PSYCHOSOCIAL ASSESSMENT

Assess factors such as:

• Mental health comorbidities (e.g., depression, anxiety).
• Family dynamics, including parental substance use and household stressors.
• Peer relationships and peer substance use.
• Trauma history or adverse childhood experiences.

When evaluating for OUD, consider conditions that mimic or overlap with its symptoms:

• Psychiatric disorders: Conditions like depression, anxiety, ADHD, and conduct disorder can present with irritability, poor concentration, or impulsivity that may mimic OUD-related behaviors.
• Chronic pain syndromes: Conditions like fibromyalgia, low back pain, or neuropathy may drive opioid use and mimic aberrant medication-seeking behaviors.
• Other substance use disorders: Co-occurring use of alcohol, benzodiazepines, or stimulants may present with withdrawal or intoxication symptoms, including sedation, agitation, or social impairment. Obtain a full substance use history.

PHYSICAL EXAM

Acute opioid intoxication may cause slurred speech, sedation, and pinpoint pupils. Adolescents with tolerance to opioids may not show a response to the typical dose of opioids in the hospital.

Withdrawal may cause dysphoria, restlessness, rhinorrhea, watery eyes, sweating, myalgia, nausea, vomiting, diarrhea, and dilated pupils.

Physical exam should include assessment for track marks from chronic intravenous use and an examination of the nasal septum for perforation from repeated intranasal insufflation.

LABORATORY TESTING

For adolescents with OUD, obtain a CBC and LFTs to screen for infection and liver dysfunction. Patients who use intravenous heroin should be screened for HIV, Hepatitis A, B, and C, syphilis, and TB.

MANAGEMENT OF OPIOID USE DISORDER

General Principles

• Engage youth and families in creating a collaborative treatment plan.
• Match treatment intensity to OUD severity (e.g., outpatient vs. residential).
• Integrate care for co-occurring medical and psychiatric conditions.
• Prescribe naloxone and provide overdose prevention education for patients and families.
• Incorporate trauma-informed care, particularly for youth with adverse childhood experiences.

Behavioral Interventions

Behavioral therapies address the underlying drivers of addiction:

• Cognitive Behavioral Therapy (CBT): Builds coping strategies and modifies substance use behaviors.
• Contingency Management: Offers incentives for treatment engagement and abstinence.
• Family-Based Therapies: Engages parents to address family dynamics and improve adherence.
• Motivational Enhancement Therapy: Resolves ambivalence and enhances motivation for change.

MEDICATIONS

Harm Reduction

For youth not ready for treatment, harm reduction minimizes risks associated with opioid use:

• Naloxone: Train patients and families to recognize and respond to overdoses.
• Safe Injection Practices: Use sterile needles, clean injection sites, and avoid sharing equipment. Refer to needle exchange programs.

Long-Term Follow-Up

Long-term follow-up is critical for sustained recovery. Regular assessments of treatment adherence, response, and evolving psychosocial needs can help adjust interventions to prevent relapse and support ongoing recovery.

REFERENCES

https://www.uptodate.com/contents/opioid-use-disorder-epidemiology-clinical-features-health-consequences-screening-and-assessmenthttps://publications.aap.org/pediatrics/article/145/Supplement_2/S153/34453/Management-of-Opioid-Misuse-and-Opioid-Use