Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Opioid Type Dependence


Related Terms

  • Codeine Dependency
  • Heroin Addiction
  • Pain Medication Abuse
  • Pain Medication Addiction

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

It has been demonstrated that the most reliable predictor of treatment outcome, regardless of treatment strategy, is the individual's readiness to change. The severity of the abuse/dependence, early intervention, the success of the treatment program, appropriate individual-treatment matching, and any physical complications may influence the length of disability as well. A stable history of employment is also a major predictor of permanent abstinence.

Medical Codes

ICD-9-CM:
304.00 - Opioid Type Dependence; Unspecified
304.01 - Opioid Type Dependence; Continuous
304.02 - Opioid Type Dependence; Episodic
304.03 - Opioid Type Dependence; in Remission

Overview

Opioid-type dependence is defined as dependence upon the class of natural or synthetic drugs that includes morphine, codeine, and heroin.

Opioids are generally prescribed as pain management medications, antidiarrheal agents, or cough suppressants and, when used regularly, cause symptoms of drowsiness, slurred speech, constricted pupil size, and attention or memory impairment. Dependence reflects prolonged use of opioid substances for non-medical purposes, or when they are used for medical purposes, that use occurs in amounts or frequencies greater than needed for pain management.

Individuals who have developed an opioid dependence have a history of regular, frequently daily, use over a period of time, with withdrawal symptoms occurring within 6 to 12 hours of the last dose. Withdrawal symptoms include depression, nausea, vomiting, diarrhea, muscle aches, excessive tearing of the eye or nose, pupillary dilation, yawning, fever, or insomnia.

Heroin is a commonly misused drug of this class and is usually injected or, occasionally, smoked or inhaled. Those individuals who depend on prescribed opioids, usually pain management medications, will frequently either illegally purchase the drug or obtain prescriptions by faking or exaggerating illnesses or by receiving prescriptions from a number of different physicians, most of whom are unaware of duplicate opioid prescriptions.

Incidence and Prevalence: Although the use of prescribed pain medications can be a risk for opioid dependency, only a small minority (between 1% and 5%) of individuals who are prescribed opiates for medical reasons develop opiate abuse or dependency (DSM-IV-TR). Roughly 1% of the US population is estimated to have used opioids during their lifetime, and studies found that 0.7% of individuals were opioid abusers or dependent in their lifetime (DSM-IV-TR).

Source: Medical Disability Advisor



Causation and Known Risk Factors

In the past decade, the number of individuals between the ages of 18 and 25 admitted into treatment for prescription painkillers has more than doubled. Women’s use of opioids is also increasing—55% of new recreational users of prescription painkillers in 2001 were women ("Opioid Dependence").

Source: Medical Disability Advisor



Diagnosis

History: The diagnosis depends upon the individual demonstrating at least three or more of the criteria established by the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) at any time in the same 12-month period. Criteria include a need for markedly increased amounts of drug to achieve intoxication; diminished effects with continued use of the same amount of drug; symptoms of withdrawal, such as tremors, increased blood pressure or heart rate, cravings, sweating, diarrhea, or fever; persistent unsuccessful attempts to quit or control drug intake; a great deal of time spent in activities related to the use of or recovery from the use of drugs; social, occupational, recreational, or relational activities given up for the sake of drug use; and continued drug use despite knowledge of recurrent physical or psychological problems related to its use.

Individuals who are in withdrawal complain of muscle cramps, nausea, anxiety, difficulty sleeping, depressed mood, and / or drug cravings.

Physical exam: Signs of opiate abuse differ significantly, depending on whether the individual presents with opiate dependence, overdose, or withdrawal. Opiate dependence is manifested by pinpoint pupils, slowed speech and movement, euphoria, and / or weight loss. Drug overdose is indicated by slow, shallow respirations; unconsciousness; pinpoint-sized pupils; and skin that is cold, moist, and bluish in color. Observable signs of heroin withdrawal include restlessness, vomiting, runny nose, sweating, diarrhea, fever, abdominal cramping, muscle cramps, dilated pupils, or yawning. Needle tracks or scars may be evident, usually in the arms, hands, feet, or groin areas. Most withdrawal symptoms resolve within a week, but some, such as anxiety or insomnia, can last for weeks to months.

Tests: Urine toxicology tests for heroin remain positive for up to 36 hours after the last dose. The intravenous (IV) drug abuser population runs a very high-risk of getting HIV; hepatitis A, B, and C; and syphilis, so tests for these diseases may be performed. Blood cultures may also be performed. A chest x-ray can rule out pulmonary fibrosis that IV drug abusers may get from injecting drugs that contain fillers of talc. Other laboratory tests such as complete blood count, liver function test, electrolytes, and blood alcohol levels may be helpful. If the patient is dependent on opioids, Naloxone will elicit narcotic withdrawal.

Source: Medical Disability Advisor



Treatment

Abstinence is the treatment goal. Treatment services may include individual psychotherapy, family therapy, drug education, and relaxation training and are usually conducted in an outpatient setting. Hospitalization may be necessary if the individual is suicidal or is having severe withdrawal symptoms during detoxification. Treatment may include education on physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; improved coping skills; assertiveness training; and relaxation training. Several types of psychotherapy, including cognitive, behavioral, dynamic, group, and aversion therapy, have been shown to help this population of substance abuse patients. Contingency management, in which individuals receive rewards or prizes for remaining abstinent, has also been shown to be helpful. Ongoing, structured self-help programs such as Narcotics Anonymous and Rational Recovery are recommended as an adjunct to treatment services. Regular but random drug screens should be part of the treatment process. Some heroin-dependent individuals enroll in medically supervised methadone-maintenance programs, in which methadone is substituted for heroin and then gradually decreased until the individual achieves abstinence.

A longer-acting opioid called L-alpha-acetyl-methadol (LAAM) has been used for maintenance treatment. The use of buprenorphine and naltrexone are being investigated for other pharmacologic means and for relapse prevention. Buprenorphine maintenance and detoxification treatment have recently become available in the US.

One approach to heroin dependence treatment is called Ultra Rapid Opioid Detox (UROD), which involves the use of opiate antagonists and general anesthesia to allow individuals to be safely detoxed within a few hours. This technique greatly shortens the time of detoxification, avoids the pain and other discomforts of withdrawal, allows sooner entry into the rehabilitation phase of a recovery program, minimizes time lost from work and family, and helps to decrease the relatively high number of individuals who leave conventional detoxification programs prematurely. However, it is a high-risk procedure requiring careful medical monitoring. Even though the success rate of this 1 to 2 day detoxification process is high, the actual measure of success is whether the individual remains abstinent over a period of time, usually after involvement with traditional outpatient addiction treatment programs.

Withdrawal symptoms, which occur for up to 7 days, may require medication management for symptoms such as nausea, diarrhea, or anxiety.

Source: Medical Disability Advisor



Prognosis

Approximately 20% to 30% of the opioid-dependent remain abstinent for a long period of time, although individuals may have relapses while they are recovering (DSM-IV-TR). Some individuals never seek treatment.

Once dependence develops, it may continue over a period of many years, with frequent periods of abstinence. It is fairly common for opiate dependence to decrease after age 40, although many individuals remain dependent for 50 years or more.

The outcome is improved if the individual seeks treatment early in the disease process and has adequate social support systems in place.

Source: Medical Disability Advisor



Rehabilitation

In addition to substance abuse treatment and support groups, occupational therapy could help the individual develop communication skills, identify and match personal skills and work habits to the workplace, and learn how non-substance-related participation in leisure activities contributes to overall health and well-being. Physical conditioning may be needed to address deconditioning that occurs because of inactivity during the period of addition and early recovery. Supportive therapies, such as expressive therapies (art, music, or dance therapy), relaxation techniques, or breath therapy, might be helpful in decreasing stress levels that some individuals perceive put them at risk for relapse.

Source: Medical Disability Advisor



Complications

Many opiate-dependent individuals also abuse alcohol, cocaine, anti-anxiety agents, sedatives, and / or other psychoactive substances and may become dependent on them as well. Users who inject the drug risk not only an overdose but also skin abscesses, infections of the heart lining and valves (endocarditis), inflammation of the membranes of the spinal cord or brain (meningitis), tuberculosis, hepatitis, or acquired immune deficiency syndrome (AIDS) from sharing needles with others.

Regular use of opiates can lead to dry mouth, visual impairment, constipation, male sexual erectile dysfunction, or female disturbances in menses. Up to 2% of dependent individuals die annually from complications of opiate dependence, usually from overdose, accidents, injuries, or AIDS (DSM-IV-TR).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Outpatient detoxification and counseling are becoming more common, and most outpatient programs enable the individual to continue working.

Many employers have systems in place that help individuals recovering from substance dependence disorders to return to work under special contracts or conditions. These conditions may include guidelines for testing blood and urine levels of identified substances and provide work performance and substance abuse treatment guidelines for the recovering individual. Opiate use should not be tolerated at the workplace because employees who use on the job endanger their safety and that of their coworkers and often create a negative work environment.

In general, temporary work accommodations may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and / or high level of alertness, such as driving a motor vehicle, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments, which normally should occur during the employee's personal time; promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote the individual's timely and safe transition back to full work productivity.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual's evaluation include a detailed history of past and present substance use; a general medical and psychiatric history and examination; a history of any/all prior psychiatric treatments with outcomes; a family and social history; screening of blood, breath, or urine for abused substances; and other laboratory tests to help confirm the presence or absence of comorbid conditions frequently associated with substance use disorders? If not, what areas were omitted?
  • Would this information affect the current treatment plan? If so, what changes can be made?
  • Have underlying medical and particularly psychiatric disorders been ruled out?

Regarding treatment:

  • Does individual require maintenance with opioid agonists?
  • Because the concurrent use of or withdrawal from other substances can complicate treatment of opioid withdrawal, has other substance use been identified and appropriately addressed?
  • Is the effectiveness of agonist drug therapy limited by lack of compliance and low treatment retention?
  • Would individual benefit from change to an alternative drug treatment strategy?
  • Was choice of treatment based on the individual's preferences, the medical issues to be addressed, associated psychiatric disorders, and individual's past response to various forms of treatment?
  • Has treatment approach been matched to the particular needs of the individual?
  • Would individual benefit from a behavioral therapy approach that uses a voucher-based system to give positive rewards for staying in treatment and remaining free from opiate usage (contingency management)?
  • Does current treatment program include cognitive behavioral interventions?
  • Does individual's life and social interactions focus predominantly on substance use?
  • Does individual lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting?
  • If individual does not meet clinical criteria for hospitalization, would he or she benefit from admission to a residential treatment program?
  • Have underlying psychiatric disorders been addressed?

Regarding prognosis:

  • Was individual treated with three or more months of residential treatment that is associated with a better long-term outcome?
  • Is individual currently involved in a support group such as Narcotics or Alcoholics Anonymous?
  • Does support group provide the external support and motivation to continue in treatment beyond the initial stage of detoxification?
  • Besides just kicking the habit, is individual receiving necessary tools, skills, and encouragement to move ahead with his or her life?

Source: Medical Disability Advisor



References

Cited

"Opioid Dependence in the United States." Suboxone. 6 Apr. 2005. 27 Jul. 2006 <http://www.suboxone.com/patients/opioiddependence/united_states.aspx>.

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Source: Medical Disability Advisor






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