A common illicit opioid is heroin, but any opioid pain medication can be "diverted" to illicit use, including hydrocodone and long-acting oxycodone. Physical dependence on an opioid is just one of the seven criteria for the diagnosis of opioid dependence, and patients who are not physically dependent on opioids can still have opioid dependence if they meet three other criteria. Unfortunately, the terminology for this disorder is confusing.
The medical disorder opioid dependence is defined as a maladaptive pattern of use of illicit or prescription opioids leading to clinically significant impairment or distress as manifested by three or more diagnostic criteria in the past 12 months.( 1) These diagnostic criteria include physical dependence, tolerance, taking opioids in larger amounts or for longer periods than intended, desiring to cut down or control use, dedicating a large amount of time to procuring opioids or recovering from their effects, giving up important activities because of their use, and using opioids despite knowledge of harm. This case provides an opportunity to discuss the basics of opiate dependence and opiate withdrawal.
Unfortunately, many providers are uncomfortable caring for patients with opiate dependence, unwilling to do so, or simply uninformed about appropriate treatment strategies. Opioid dependence is a treatable chronic medical illness that afflicts as many as 6 million persons in the United States. He was given increased methadone to treat presumed worsening opiate withdrawal. On physical examination, he was tachycardic, tachypneic, and generally restless, but had a nontender abdominal examination. He also complained of excessive yawning and increased lacrimation.
Later in the evening of admission, he complained of increasing diffuse abdominal pain. He was admitted to the hospital for treatment of dehydration and opiate withdrawal and was given intravenous fluids, methadone, and low doses of morphine intravenously for the abdominal pain. His complete blood count, liver function tests, amylase, and lipase were all normal, and an upright KUB radiograph showed no clear cause for his abdominal pain. On initial evaluation, he was dehydrated, but his vital signs were unremarkable and his abdominal examination was benign. He said he had been using less heroin than usual because of the gastrointestinal complaints and felt that his symptoms were probably from heroin withdrawal.
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