Why Is Opioid Misuse Underdiagnosed?

Opioid misuse is underdiagnosed for a number of reasons, including lack of education of healthcare providers on how to screen, misdiagnosis of pain, among others. Learn more here. 

The Relationship Between Pain & OUD

Opioid use disorder (OUD) often begins with legitimate issues relating to pain. While not true for everyone, we do know that the majority of patients with OUD report that their first interaction with opioids was through a prescription written by their doctor, usually legally, for pain. 

When patients have acute severe pain, we often use opioids, as they are arguably the strongest class of pain medications we have. They are very effective – and indicated – for short term use. The problem is when they are given for pain conditions that become chronic. All major expert societies on pain advise against the use of long term opioids for chronic pain conditions, with the exception of cancer/malignancy related pain, because we now understand that the risks of addiction and overdose greatly outweigh the benefits. Unfortunately, for many patients, it is too late: they have been on opioids for months or even years and are now physically dependent on these medications and very afraid to live without them. 

In addition, in spite of these well established guidelines, many doctors still give in and prescribe opioids to patients long term, particularly when other therapies or medications have been insufficient to control the patient’s pain. 

With time, the body’s pain receptors become sensitized to opioids, and patients may require higher and higher doses of opioids in order to achieve the same level of pain control. This is called tolerance. 

Simultaneously, as the body is constantly exposed to more opioids, it can actually develop increased sensitivity to pain, either at the site of the previous injury or even in all new parts of the body. Patients who used to simply have back pain now are sensitive to pain stimuli other joints, muscles, and “all over”. This is a phenomenon called “opioid induced hyperalgesia”, where chronic opioids actually make the pain worse. Instead of recognizing this as a consequence of the medication itself, patient’s may simply feel that the medication is not working the way it used to and request more, and a vicious cycle can develop. 

With this in mind, any initiation of a new opioid prescription is a calculated risk. Patients should always be made aware of the risks of these medications, and expectations should be set about what opioids can and cannot do long term for pain control. In addition, opioids should always be given in as low doses as possible and for the shortest amount of time necessary. 

Overprescription of Opioids

One of the reasons OUD can go unrecognized is because we as a society have chronically over-prescribed opioid medications and normalized their use, which has greatly contributed to the current opioid epidemic.[3] In 2017, there were 58 opioid prescriptions written for every 100 Americans, and the average number of days per prescription continues to rise, with the number sitting at 18 days that same year.[4] As compared to other countries, we prescribed significantly more opioids for pain, more so than any other country in the world. 

After recognizing this problem in recent years, there have been some positive changes to prescribing trends. While still high, opioid prescription rates are falling, and being used for shorter durations for appropriate conditions. [4] Nonetheless, many individuals still receive opioid prescriptions for long courses and for conditions which they are not indicated. 

Underdiagnosis of Opioid Misuse

Unfortunately, when opioid use disorder does occur, doctors are not always good at identifying it: 

A 2020 study found both opioid use disorder as well as alcohol use disorder (AUD) were underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. [1] Another study published in 2022  also noted issues related to underdiagnosis of OUD in health system settings, this time with a focus on electronic health records (EHRs).[2] EHRs often fail to include that a patient likely has an OUD, even when there are documented signs and symptoms of OUD and social risks and behaviors associated with that same patient elsewhere. 

The reasons why doctors may not identify OUD are many. First, office visits are short and doctors are very busy. Asking the appropriate questions takes time, and doctors may be too busy to ask all the necessary questions. In addition, doctors may not ask because they do not know alot about addiction medicine and do not feel comfortable helping the patient seek treatment even if they do screen positive for an opioid use disorder. The doctor may also have limited behavioral health specialists or addiction specialists that they can refer patients to, particularly in rural or underserved areas. Lastly, doctors may not be aware that their patient is receiving opioids from another provider. Some states do have prescription drug monitoring programs, but these are limited and not always reliable. Patients may not be forthcoming about all the medications they are taking, including opioids, and their doctor therefore may not be able to accurately assess their risk or adequately counsel them. 

Dependence vs. Opioid Misuse

There is a difference between opioid dependence and opioid misuse. Dependence refers to physical dependence on a medication such that, when a person abruptly stops taking that medicine, they experience adverse side effects. 

An opioid use disorder, in contrast, refers to the continued use of a medication or substance in spite of the negative consequences it has on their life or their ability to function. 

A person may or may not have physical dependence on opioids and still have an opioid use disorder. 

For example, a patient may take their medicine exactly as prescribed every day, and have no negative consequences as a result of taking the medication. However, if they stop taking the medication, they feel nauseous, shaky and weak. This is an example of dependence without OUD. 

In contrast, a person may really like the feeling of analgesia and euphoria they get when they crush and snort an oxycodone pill. They may be able to do this and still feel fine the next day and not have any withdrawal symptoms. This is an example of opioid misuse without physical dependence. 

The Bottom Line: Is it A “Diagnosis” of OUD?

Because people’s experience and behavior with opioids is so varied, there are a lot of different terms and definitions in addiction medicine. The best question to ask is: 

‍“ Is taking these medications or substances in the way that you do causing negative consequences in your social life or to your health, and are you taking the medications in spite of these negative consequences?”

If so, it doesn’t matter whether you call it opioid dependence, misuse, or opioid use disorder. The most important thing is that you recognize this might be a more concerning sign and you should reach out to friends, family and hopefully medical professionals for help and next steps. 

Using Suboxone to Treat OUD

The good news is that, even though OUD is still under-recognized, it is treatable once it is identified. The FDA has approved three medications for the treatment of OUD: Methadone, Suboxone, and Vivitrol. 

Suboxone is the most commonly prescribed in the outpatient setting for OUD. Suboxone has been shown to be very effective in combating opioid use disorder when used as part of a Medication for Addiction Treatment (MAT) plan. The medications used in MAT are given in conjunction with therapy, as individuals learn how to cope with underlying issues that contribute to their substance misuse.

‍Numerous studies have found Suboxone and similar drugs can help people in opioid addiction treatment to stay in treatment and get more positive results from that treatment.[5] Suboxone reduces a patient’s risk of relapse, lowers their risk of overdose, and improves their chance of a sustained recovery. 

Buprenorphine is still a new treatment and many providers have been practicing long before it was so mainstream. Therefore, some providers are less familiar with it and more hesitant to prescribe it. This leads to the continued underprescribing of these potentially life saving medications. [6] 

The medical community is continuing to educate providers about the benefits of Suboxone and how to prescribe it safely and effectively. [7] Access to this medication continues to expand as more and more providers prescribe it to patients as an important tool in our toolbox in the fight against OUD.

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Header Photo by Christina Victoria Craft on Unsplash