Letter: Error in Estimating Prevalence of Iatrogenic Opioid Use Disorder

Dear Editor:

We think the authors of the New England Journal of Medicine Perspectives piece on iatrogenic opioid use disorder misapplied the Diagnostic and Statistical Manual (DSM) criteria for opioid use disorder (OUD) to overestimate the population of patients in the United States. ¹

The first sentence of the DSM’s OUD diagnostic criteria, “A problematic pattern of opioid use leading to clinically significant impairment or distress…” seems to have been missing from the author’s criteria. Yet, the key to the following 11 criteria is that they must be causing some significant impairment or distress. It is not clear if the patients surveyed were experiencing this level of impact when answering the screening tool positively. In our clinical practices, particularly in the current setting of severe restrictions on provider willingness to prescribe medicinal opioids, and pharmacy willingness to stock and dispense medical opioids patients and their families and their health care providers are worried about their supplies. Further, the DSM qualifier for tolerance or withdrawal specifies they should not be included if the patient is taking the opioid “solely under appropriate medical supervision.” We think the authors, and the Department of Health and Human Services (DHHS) using the National Survey on Drug Use and Health (NSDUH) may be simplifying the assessment and diagnosis too much. This then erroneously leads them to jump to the startling conclusion they are reporting in this piece.

We do see patients who qualify for OUD who are taking opioids prescribed by a physician. But they pale in number to the vast majority who take their opioids appropriately. More commonly, we see patients under-treated out of fear of causing OUD on the part of the prescriber. We imagine most of these patients who take medicinal opioids are negatively impacted by the opioids being in their lives and would answer positively to the survey tool. But that would not substantiate the leap to the huge number of people with profound functional impairment. Sadly, we fear this piece will feed the unwarranted opiophobia that has reinfected those caring for patients with advanced cancer and other diseases.