Opioid Abuse Differential Diagnoses

Updated: Sep 05, 2023
  • Author: David W Dixon, DO; Chief Editor: Glen L Xiong, MD  more...
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Diagnostic Considerations


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%).

Differential Diagnoses