Arguments for and Against a New Diagnostic Entity for Patients With Chronic Pain on Long-Term Opioid Therapy for Whom Harms Outweigh Benefits

Abstract

The goal of this study was to understand perspectives on whether a new diagnostic entity, distinct from Diagnostic and Statistical Manual - 5 (DSM-5) opioid use disorder (OUD), is needed for patients with chronic pain on long-term opioid therapy (LTOT) for whom the harms of continued opioid therapy outweigh the benefits. Data were collected as part of a larger Delphi study. We used rapid and thematic qualitative methods to analyze data from 51 panelists with expertise in internal medicine, psychiatry, psychology, and related fields. Three-quarters of panelists supported a new diagnostic entity; common themes included recognizing distinct experiences of patients prescribed LTOT, addressing problems with DSM-5 OUD criteria, facilitating research and improved treatment, and reducing stigma. Thirteen panelists opposed the creation of a new diagnostic entity; common themes included similarities in biological underpinnings of patients prescribed LTOT and diagnosed with OUD, belief that the continuum of OUD captured patients' experiences, finding better ways to address problems with DSM-5 OUD criteria, and concerns about stigma. While this expert panel disagreed about the need for a new diagnostic entity, there was an overall acknowledgement that the current implementation of DSM-5's OUD diagnosis is not meeting the needs of LTOT providers or patients. PERSPECTIVE: The DSM-5's OUD diagnosis may not adequately meet the needs of patients on LTOT for whom the harms of continued opioid therapy outweigh the benefits. Experts do not agree on how to address this problem; more work is needed to determine if a new diagnostic entity would be beneficial.

Keywords: Chronic pain; long term opioid therapy; opioid use disorder; stigma; tapering.