Opioid analgesics have long been a cornerstone in the treatment of moderate to severe pain, particularly for patients with acute injuries, post-surgical pain, or chronic pain conditions such as cancer and degenerative spine disorders. However, the prolonged use of opioids—even when medically indicated—carries the risk of developing opioid use disorder (OUD). Recognizing OUD in patients who are prescribed opioids for pain management can be challenging, as symptoms of dependence may overlap with the behaviors of individuals in legitimate pain. Nonetheless, timely identification is essential to ensure safe, effective treatment and to prevent long-term harm.
Opioid use disorder is a medical condition characterized by a problematic pattern of opioid use that leads to clinically significant impairment or distress. It is distinct from physical dependence and tolerance, which are expected physiological responses to long-term opioid therapy. Patients receiving opioids under appropriate medical supervision may develop these physical adaptations without meeting the criteria for OUD. The challenge lies in differentiating between appropriate medical use and behaviors indicative of misuse or addiction.
Healthcare providers should be aware of the behavioral and psychological signs that suggest opioid use disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), criteria for OUD include taking opioids in larger amounts or for longer than prescribed, unsuccessful efforts to cut down, spending excessive time obtaining or using opioids, and continued use despite negative personal or social consequences. Other red flags may include persistent cravings, withdrawal from normal activities, and use in hazardous situations. Notably, tolerance and withdrawal alone are not sufficient for diagnosis in patients who are using opioids as directed by a healthcare provider.
Clinicians often encounter patients who request early refills, report lost prescriptions, or insist that their current dose is inadequate. While these behaviors may indicate OUD, they can also be signs of poorly managed pain or what is known as “pseudoaddiction,” where patients exhibit drug-seeking behavior due to undertreated pain. In these cases, increasing the opioid dose may actually improve the patient’s behavior by addressing the underlying pain. Therefore, careful clinical judgment and a comprehensive evaluation are essential.
One of the most effective ways to monitor and assess the risk of opioid use disorder is through regular patient engagement. Clinicians should take a thorough history that includes any personal or family history of substance use, mental health disorders, or previous issues with pain medications. They should also assess the patient’s functionality, psychological well-being, and overall quality of life. Routine follow-up visits provide an opportunity to observe any behavioral changes and to reevaluate the effectiveness and necessity of opioid therapy.
While tools like the Opioid Risk Tool (ORT) or the Screener and Opioid Assessment for Patients with Pain (SOAPP) can be useful for identifying patients at higher risk for misuse, they should not replace clinical insight. Similarly, prescription drug monitoring programs (PDMPs) can offer valuable information about a patient’s prescription history, helping to detect patterns such as “doctor shopping” or obtaining opioids from multiple pharmacies.
When signs of opioid use disorder are identified, the response should be both compassionate and evidence-based. This may involve tapering the opioid dosage, introducing non-opioid therapies, or referring the patient to a specialist for further evaluation. In cases where a diagnosis of OUD is confirmed, medication-assisted treatment (MAT) with buprenorphine or methadone, along with behavioral therapy, may be appropriate.
Recognizing opioid use disorder in patients receiving opioid analgesics for pain is a nuanced process. It requires vigilance, a comprehensive understanding of the patient’s pain condition, and the ability to distinguish between therapeutic use and problematic behavior. By combining clinical observation with structured assessment tools and open communication, healthcare providers can identify opioid misuse early, intervene appropriately, and continue to provide compassionate and effective pain management. This balanced approach is essential for navigating the complexities of opioid therapy in today’s healthcare landscape.