eMedicine Specialties > Psychiatry > Addiction

Opioid Abuse: Differential Diagnoses & Workup

Author: William J Meehan, MD, Chief Resident in Clinical Research, Department of Psychiatry, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School
Coauthor(s): Steven A Adelman, MD, Director, Behavioral Health and Addiction Medicine, Harvard Vanguard Medical Associates
Contributor Information and Disclosures

Updated: Jul 31, 2009

Differential Diagnoses

Gastroenteritis, Bacterial
Pancreatitis, Chronic
Gastroenteritis, Viral
Peptic Ulcer Disease
Influenza
Toxicity, Barbiturate
Pancreatitis, Acute
Toxicity, Benzodiazepine

Other Problems to Be Considered

Sepsis
Antisocial personality
Panic attack
Pontine infarct or hemorrhage
Depressed mood

Although GI symptoms of nausea, vomiting, and abdominal pain are predominant and common in opioid withdrawal, they may warrant consideration of gastroenteritis, pancreatitis, peptic ulcer disease, and intestinal obstruction.

Sympathetic overactivity must lead to consideration of panic attacks and CNS stimulants, such as amphetamines.

Because multi-drug abuse is common, investigate intoxication by drugs other than narcotics (benzodiazepines, barbiturates) in unconscious patients. A person who abuses opioids may conceal information about other abusive drugs. Because opioid intoxication generally does not cause tremulousness, delirium, and seizures, their presence should raise suspicion of alcohol and benzodiazepine dependence.

Small-sized pupils are observed in opioid intoxication, pontine lesions, and local cholinergic drops.

An antisocial personality may be mistaken as addictive behaviors (and vice versa), especially if confrontation with the law is involved.

Besides opioid-induced psychiatric disorders, a high prevalence of non–opioid-related psychiatric disorders exists. In Baltimore during the early 1990s, a study of people who were addicted and treated with methadone was performed, and the lifetime prevalence of comorbid mood and anxiety disorders was 19% and 8.2%, respectively. Lifetime rates of personality disorders in decreasing frequency were as follows:

  • Antisocial disorder (25.1%)
  • Avoidant disorder (5.2%)
  • Borderline disorder (5.2%)
  • Passive aggressive disorder (4.1%)
  • Paranoid disorder (3.2%)
In women, depression, anxiety disorders, and borderline personality disorder were considerably more common, and antisocial personality disorder was less common compared to males.

In the same study, comorbid dependence was also observed for cocaine (64.7%), cannabis (50.8%), alcohol (50%), and sedatives (46.6%).

Workup

Laboratory Studies

  • Abuse and dependence
    • Urine drug screen
    • Detection of drugs in sweat and hair is a recent addition to drug abuse detection technology. However, it is not used widely.
  • Withdrawal
    • Electrolytes
    • CBC count
    • Urine drug screen is rarely useful.
  • Intoxication
    • Comprehensive urine drug testing is performed when the drug abuse habit of the patient is unknown but suspected. Some labs use the inexpensive thin-layer chromatography (TLC) procedure. This test has low sensitivity for commonly used drugs. TLC cannot detect fentanyl.
    • Enzyme immunoassay and radioimmunoassay are more sensitive than TLC, but they are less specific because molecules with similar functional groups cross-react with antibodies. These are relatively inexpensive tests.
    • Gas-liquid chromatography (GLC) and gas chromatography-mass spectrometry (GC-MS) are very sensitive and specific tests, but they are time consuming, labor intensive, and expensive.
    • In drug abuse detection, knowing the half-life of the drug, the biotransformation of the drug, and the excretion route of the drug are important.
    • Screening and confirmation cut-off concentration for heroin, methadone, morphine, and codeine is 300 ng/mL and are detected in urine within 1-4 days.
    • False-negative results occur more easily than false positives, simply because once a test is screened negative, it is not tested further. The federal government requires that the results of the drug testing programs go directly to medical review offices to prevent improper interpretation of drug testing data.
    • Blood alcohol levels also may be tested.
  • Addiction: In case of historical or clinical evidence of IV drug abuse, perform the following:
    • LFT
    • Rapid plasma reagent (RPR)
    • Hepatitis viral testing
    • HIV testing
    • Blood cultures (in appropriate clinical setting)

Imaging Studies

For addiction, in case of historical or clinical evidence of IV drug abuse, perform an x-ray of the lungs (eg, history of injecting drugs contaminated with microcrystalline talc) to search for evidence of pulmonary fibrosis.

Other Tests

Naloxone challenge test: This test is performed to assess physical dependence. As an intramuscular injection or IV, 0.2-0.8 mg of naloxone is administered.

  • A positive test is indicative of physical dependence and consists of typical withdrawal symptoms and signs. These symptoms and signs usually last for 30-60 minutes.
  • This test is found to be very helpful before starting opiate antagonists for maintenance therapy. Starting opioid antagonists, such as naltrexone, soon after detoxification may cause withdrawal symptoms and discourage patients from further treatment.

More on Opioid Abuse

Overview: Opioid Abuse
Differential Diagnoses & Workup: Opioid Abuse
Treatment & Medication: Opioid Abuse
Follow-up: Opioid Abuse
Multimedia: Opioid Abuse
References
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Further Reading

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Keywords

opioid abuse, narcotic abuse, drug abuse, pain relievers, endorphins, heroin, morphine, opium, PCP, opioid receptors, intravenous drug use, IV drug use, intravenous drug user, IDU, drug dependence, pain reliever abuse

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Contributor Information and Disclosures

Author

William J Meehan, MD, Chief Resident in Clinical Research, Department of Psychiatry, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School
Disclosure: Nothing to disclose.

Coauthor(s)

Steven A Adelman, MD, Director, Behavioral Health and Addiction Medicine, Harvard Vanguard Medical Associates
Steven A Adelman, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Psychiatric Association, American Society of Addiction Medicine, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Barry I Liskow, MD, Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center
Barry I Liskow, MD is a member of the following medical societies: American Academy of Clinical Psychiatrists, American Academy of Psychiatrists in Alcoholism and Addictions, American Medical Association, American Psychiatric Association, and Research Society on Alcoholism
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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