Opioid Abuse Workup
- Author: Adrian Preda, MD; Chief Editor: Eduardo Dunayevich, MD more...
Abuse and dependence
See the list below:
- 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.
See the list below:
- CBC count
- Urine drug screen is rarely useful.
See the list below:
- 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.
In case of historical or clinical evidence of IV drug abuse, perform the following:
- Rapid plasma reagent (RPR)
- Hepatitis viral testing
- HIV testing
- Blood cultures (in appropriate clinical setting)
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.
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.
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.
CDC. Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. CDC. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e1218a1.htm. December 18, 2015; Accessed: December 24, 2015.
Trust for America's Health and the Robert Wood Johnson Foundation. The Facts Hurt: A State-By-State Injury Prevention Policy Report. The Facts Hurt: A State-By-State Injury Prevention Policy Report. June 2015. Available at http://www.healthyamericans.org/reports/injuryprevention15/.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 541-46.
[Guideline] American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd edition. In American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, VA: American Psychiatric Association, 2006 (pp. 291–563). Available at http://psychiatryonline.org/content.aspx?bookid=28§ionid=1675010.
Brooks M. FDA clears hydrocodone with abuse-deterrent properties. Medscape Medical News. November 20, 2014. [Full Text].
Lowes R. FDA Restricts Long-term Opioid Use to Combat Abuse. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810732.. Accessed: September 18, 2013.
CDC. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm. March 15, 2016; Accessed: March 16, 2016.
Brooks M. Grim stats for opioid-related deaths, prescribing in US. Medscape Medical News. July 2, 2014. [Full Text].
Opioid painkiller prescribing: where you live makes a difference. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing. Accessed: July 6, 2014.
Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines - United States, 2012. MMWR Morb Mortal Wkly Rep. 2014 Jul 4. 63(26):563-8. [Medline].
Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables. September 10, 2015. [Full Text].
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011 Apr 6. 305(13):1315-21. [Medline].
[Guideline] Brooks M. New APS Guideline on Safe Use of Methadone. Medscape Medical News. May 22 2014. [Full Text].
[Guideline] Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014 Apr. 15(4):321-37. [Medline].
Reimer J, Verthein U, Karow A, et al. Physical and mental health in severe opioid-dependent patients within a randomized controlled maintenance treatment trial. Addiction. 2011 Sep. 106(9):1647-55. [Medline].
Grella CE, Lovinger K. 30-Year trajectories of heroin and other drug use among men and women sampled from methadone treatment in California. Drug Alcohol Depend. 2011 Nov 1. 118(2-3):251-8. [Medline]. [Full Text].
Martin BC, Fan MY, Edlund MJ, et al. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011 Dec. 26(12):1450-7. [Medline].
Richardson LP, Russo JE, Katon W, McCarty CA, Devries A, Edlund MJ, et al. Mental Health Disorders and Long-term Opioid Use Among Adolescents and Young Adults With Chronic Pain. J Adolesc Health. 2012 Jun. 50(6):553-8. [Medline]. [Full Text].
Saxon AJ, Oreskovich MR, Brkanac Z. Genetic determinants of addiction to opioids and cocaine. Harv Rev Psychiatry. 2005 Jul-Aug. 13(4):218-32. [Medline].
Narcan Nasal Spray (naloxone intranasal) [package insert]. Radnor, PA: Adapt Pharma, Inc. November, 2015. Available at [Full Text].
FDA News Release. FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm. 2015 Nov 18; Accessed: November 18, 2015.
Cassels C. FDA Okays Handheld Autoinjector for Opioid Overdose. Medscape Medical News. Available at http://www.medscape.com/viewarticle/823039. Accessed: April 9, 2014.
FDA Okays Handheld Autoinjector for Opioid Overdose. Medscape. Available at http://www.medscape.com/viewarticle/823039. Accessed: April 3, 2014.
Community-based opioid overdose prevention programs providing naloxone - United States, 2010. MMWR Morb Mortal Wkly Rep. 2012 Feb 17. 61:101-5. [Medline].
Amato L, Davoli M, A Perucci C, et al. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat. 2005 Jun. 28(4):321-9. [Medline].
Simoens S, Matheson C, Bond C, et al. The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Br J Gen Pract. 2005 Feb. 55(511):139-46. [Medline].
Ling W, Amass L, Shoptaw S, et al. A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trials Network. Addiction. 2005 Aug. 100(8):1090-100. [Medline].
Sigmon SC, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, et al. A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers. JAMA Psychiatry. 2013 Oct 23. [Medline].
Cassels C. Longer Taper May Boost Abstinence Rates in Opioid Abusers. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/813231. Accessed: November 4, 2013.
Fiellin DA, Schottenfeld RS, Cutter CJ, et al. Primary Care-Based Buprenorphine Taper vs Maintenance Therapy for Prescription Opioid Dependence: A Randomized Clinical Trial. JAMA Intern Med. 2014 Oct 20. [Medline].
Cassels C. FDA Approves New Treatment for Opioid Dependence. Available at http://www.medscape.com/viewarticle/807379. Accessed: July 19, 2013.
Cassels C. FDA approves Bunavail for opioid addiction. Medscape Medical News. June 10, 2014. [Full Text].
McCance-Katz EF. Office-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry. 2004 Nov-Dec. 12(6):321-38. [Medline].
FDA. FDA approves first buprenorphine implant for treatment of opioid dependence. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm503719.htm. May 26, 2016; Accessed: June 7, 2016.
Ling W, Casadonte P, Bigelow G, Kampman KM, Patkar A, Bailey GL, et al. Buprenorphine implants for treatment of opioid dependence: a randomized controlled trial. JAMA. 2010 Oct 13. 304(14):1576-83. [Medline].
Gowing L, Farrell M, Bornemann R. Substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev. 2004. [Medline].
Tsui JI, Herman DS, Kettavong M, Anderson BJ, Stein MD. Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms. Pain. 2011 Nov. 152(11):2640-4. [Medline]. [Full Text].
Comer SD, Sullivan MA, Yu E, et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006 Feb. 63(2):210-8. [Medline].
Krupitsky E, Nunes EV, Ling W, et al. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011 Apr 30. 377(9776):1506-13. [Medline].
Tiihonen J, Krupitsky E, Verbitskaya E, et al. Naltrexone Implant for the Treatment of Polydrug Dependence: A Randomized Controlled Trial. Am J Psychiatry. 2012 Feb 17 [Epub ahead of print].
Melville N. COMT Inhibitors Up Adherence to Opioid Maintenance Treatment. Medscape Medical News. Available at http://www.medscape.com/viewarticle/817481. Accessed: December 16, 2013.
Zhang XL, Shi J, Zhao LY, Sun LL, Wang J, Wang GB. Effects of stress on decision-making deficits in formerly heroin-dependent patients after different durations of abstinence. Am J Psychiatry. 2011 Jun. 168(6):610-6. [Medline].
Passetti F, Clark L, Davis P, et al. Risky decision-making predicts short-term outcome of community but not residential treatment for opiate addiction. Implications for case management. Drug Alcohol Depend. 2011 Oct 1. 118(1):12-8. [Medline].
Kleber HD, Gold MS, Riordan CE. The use of clonidine in detoxification from opiates. Bull Narc. 1980. 32(2):1-10. [Medline].
Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal. Cochrane Database Syst Rev. 2004. [Medline].
Gowing L, Farrell M, Ali R. Alpha2 adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev. 2004. [Medline].
Kunoe N, Lobmaier P, Vederhus JK, Hjerkinn B, Hegstad S, Gossop M, et al. Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial. Br J Psychiatry. 2009 Jun. 194(6):541-6. [Medline].
Hulse GK, Morris N, Arnold-Reed D, Tait RJ. Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone. Arch Gen Psychiatry. 2009 Oct. 66(10):1108-15. [Medline].
Marsch LA, Bickel WK, Badger GJ, et al. Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial. Arch Gen Psychiatry. 2005 Oct. 62(10):1157-64. [Medline].
Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Syst Rev. 2011 Sep 7. 9:CD005031. [Medline].
Morasco BJ, Gritzner S, Lewis L, et al. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2010 Dec 22. [Medline].
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006 Jan 17. 144(2):127-34. [Medline].
Centers for Disease Control and Prevention (CDC). Vital Signs: Risk for overdose from methadone used for pain relief – United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012 Jul. 3;61:[Full Text].
Cassels C. Illicit Use of Pain Meds a Gateway to Heroin Abuse. Medscape Medical News. Available at http://www.medscape.com/viewarticle/809812.. Accessed: August 27, 2013.
Cicero TJ, Inciardi JA, Munoz A. Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004. J Pain. 2005 Oct. 6(10):662-72. [Medline].
Davenport L. Avoid Buprenorphine Detox for Prescription Opioid Addiction. Medscape Medical News. Oct 23 2014. [Full Text].
Fischer B, Rehm J, Kim G, Kirst M. Eyes wide shut?--A conceptual and empirical critique of methadone maintenance treatment. Eur Addict Res. 2005. 11(1):1-9; discussion 10-4. [Medline].
Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA). Available at http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf.. Accessed: August 27, 2013.