{"doi":"10.1111/add.16349","title":"In the balance: No new diagnosis needed in addition to opioid use disorder to study harms associated with long‐term opioid therapy","abstract":"DSM-5 criteria for opioid use disorder contain the two elements of the proposed new diagnosis plus nine other criteria describing opioid-related harms. DSM-5 criteria provide a better way to understand risks of opioid pain medication than a new diagnosis exclusively for patients prescribed long-term opioid therapy for pain. The inability to reduce or discontinue opioids when benefits do not outweigh harms is concerning and needs to be assessed in patients on long-term opioid therapy for pain (LTOT). Overwhelming evidence finds that increased opioid prescribing fueled by assurances that addiction is rare during LTOT has led to opioid-related harms including falls, overdoses, suicides and opioid use disorder (OUD) [1]. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for OUD better describe opioid-related risks than a new diagnosis exclusively for patients prescribed LTOT. Decades of research on current and previous DSM criteria support the validity of the OUD diagnosis. Previous editions of the DSM contained two forms of substance use disorders (SUD)—‘substance abuse’ (diagnosed by meeting one of four criteria) and ‘substance dependence’ (diagnosed by meeting three of seven additional criteria including ‘tolerance’ and ‘withdrawal’). The DSM-5 workgroup found no clustering of specific criteria such as ‘loss of control’ with the more severe end of the SUD spectrum [2]. Rather, increasing numbers of criteria met indicated increasing severity of SUD. In DSM-5, an exception was made to exclude ‘tolerance’ and ‘withdrawal’ when diagnosing OUD if opioids are taken ‘under appropriate medical supervision’ [3]. This exclusion was created to avoid an OUD diagnosis in patients prescribed LTOT because these signs are routinely expected. The exclusion was not because these signs did not predict harm or correlate with other OUD criteria. Both elements of the proposed new LTOT diagnosis are already described by DSM-5 OUD criteria 2 and 9 (see Table 1). ‘Difficulty tapering LTOT’ is indistinguishable from DSM-5 OUD criterion 2 ‘unsuccessful efforts to cut down or control opioid use’. In those with OUD, difficulty cutting down or discontinuing opioid use is driven both by a desire for the positive effects of intoxication and by an imperative to avoid withdrawal and other aversive symptoms such as pain. As tolerance increases, these aversive symptoms are exacerbated during withdrawal. Gradually, avoidance of withdrawal-associated discomfort becomes the major driver for continued substance use [4]. Criterion 9 states that one continues opioid use ‘despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance’; that is, patients continue opioid use although ‘benefits do not outweigh harms’. Clinically, this occurs when patients, after being informed of LTOT harms and risks and evidence of low benefit, nonetheless decline a change in opioid prescribing. If OUD criteria 2 and 9 are present, then a diagnosis of mild OUD is indicated and sufficient for medication treatment (e.g. buprenorphine). The proposal to create a new diagnosis that includes two of the 11 DSM-5 SUD criteria may have unintended consequences including underestimating opioid-related harms, undermining informed consent for pain treatment and further disenfranchising those with illicit OUD. There is urgent need to help clinicians and patients determine harms and benefits of LTOT for chronic pain. This is best done by following the 2022 Centers for Disease Control and Prevention (CDC) Guidelines for Prescribing Opioids for Pain Recommendation 12 to use DSM-5 OUD criteria [5]. Research determining harms would be enhanced by systematically assessing all 11 DSM-5 SUD criteria in patients receiving LTOT. Assessing all 11 DSM-5 criteria including tolerance and withdrawal would provide insight into additional LTOT-related harms not assessed by the proposed new diagn","journal":"Addiction","year":2023,"id":388876,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":1,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9539,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1158342,"name":"Ellen L. Edens","orcid":"0000-0002-0786-6582","position":1,"is_corresponding":false},{"id":986122,"name":"Jodie Trafton","orcid":null,"position":2,"is_corresponding":false},{"id":236280,"name":"Wilson M. Compton","orcid":"0000-0003-3108-5118","position":3,"is_corresponding":false},{"id":1158341,"name":"Karen Drexler","orcid":"0000-0001-5576-5703","position":0,"is_corresponding":true}],"reference_count":5,"raw_metadata":null,"created_at":"2026-07-19T01:18:18.214733Z","pmid":"37766392","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}