Diagnosing opioid addiction in people with chronic pain

Over the past two decades, a steep rise in the number of opioids dispensed for pain treatment has been accompanied by a dramatic rise in overdose deaths in the United States.1 In 2016, up to 32 000 deaths reportedly involved prescription opioids,2 and the economic burden of prescription opioid overdose has been estimated to exceed $78bn (£59bn; €67bn) annually.3 Despite all the evidence of harm, however, it remains unclear exactly how to determine if a patient with chronic pain has opioid addiction, or what criteria should serve as a gold standard in making a diagnosis of opioid use disorder (OUD) in this context. This is an important gap in the literature that hinders both evidence based care and research on the links between prescription opioids and OUD. In this editorial, we discuss the limitations of diagnosing OUD in people with chronic pain, and make several recommendations for further research.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides a widely used set of diagnostic criteria for OUD. These criteria, however, do not always apply to patients who are prescribed opioids for chronic pain. According to DSM-5, if a patient presents with two out of nine specific symptoms (box 1), it may indicate …