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 Dependence


Related Terms

  • Codeine Dependency
  • Heroin Addiction
  • Opioid Use Disorder
  • 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 dependence is defined as dependence upon the class of natural opioids (morphine), semisynthetic opioids (heroin), and synthetic opioids with morphine-like action (codeine, hydromorphone, methadone, oxycodone, meperidine, fentanyl). This class also includes medications such as pentazocine and buprenorphine that have both opiate agonist and antagonist effects, because their agonist properties cause similar physiological and behavioral effects as classic opioid agonists (especially at lower doses). In DSM-5, the category that this condition comes under is called Substance Related and Addictive Disorders. The particular subtopic that is more or less the equivalent is Opioid Use Disorder, although Opioid Intoxication and Opioid Withdrawal are also diagnoses that can be made in DSM-5.

Opioids are generally prescribed as pain management medications (analgesics or anesthetics), antidiarrheal agents, or cough suppressants (antitussives) 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, use 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 an extended period, 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, goose flesh (hence the name "cold turkey"), sudden muscle activity ("kick-the-habit"), or insomnia.

Heroin is a commonly misused drug of this class and is usually injected or, occasionally, highly pure heroin can be smoked or inhaled ("snorted"). Fentanyl is injected, and cough suppressants and antidiarrheal agents are taken orally. Other opioids are taken both by injection and orally. 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.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: CDC data showed that overdose deaths from prescription opioids and from heroin continued to rise in 2011. Prescription opioid deaths increased by approximately 2%, to 16,917, whereas heroin deaths increased by 44%, from 3036 in 2010 to 4397 in 2011. Deaths involving benzodiazepines, commonly used in combination with opioids, accounted for 31% of opioid overdose deaths in 2011, an increase from 30% in 2010. Opioid dependence affects nearly 5 million people in the United States and leads to approximately 17,000 deaths annually (Preda).

Source: Medical Disability Advisor



Causation and Known Risk Factors

In 2006, 2.2 million persons aged 12 or older used prescription pain relievers illicitly for the first time. This is more than any other illicit drug, surpassing marijuana (2.1 million new users), and dwarfing heroin (91,000 new users). While past year initiates for prescription pain relievers increased 63% from 1997-2006, past year initiates for heroin decreased by 20% during that same period. The great majority of illicitly used prescription opioids are obtained from 1 physician, not from drug dealers (Preda).

Source: Medical Disability Advisor



Diagnosis

History: Individuals with opioid dependence develop regular patterns of compulsive drug use; daily activities typically revolve around obtaining and administering opioids. Opioids are usually purchased on the illegal market but may also be obtained by prescription. Signs and symptoms of opioid dependence are secondary to compulsive, prolonged self-administration of opioids for no legitimate medical purpose or, in the presence of a medical condition that requires opioid treatment, but in much larger doses than needed for pain relief.

In diagnosing opioid use disorder, the following guidelines are used. Those affected will have a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by 2 or more (as specified in the DSM-5) and at least 3 (as specified in the DSM-IV-TR) of the following, occurring within a one-year period: Opioids are often taken in larger amounts or over a longer period than was intended. There is a persistent desire or failed efforts to reduce or control opioid use. Much time is spent in activities necessary to obtain opioid, use opioid, or recover from its effects. There is craving (a strong desire or urge to use opioid). There is recurrent opioid use that results in a failure to fulfill major role obligations at work, school, or home. There is continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioid. The individual gives up or reduces important social, occupational, or recreational activities because of opioid use. There is recurrent opioid use when it is physically hazardous. The individual 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 opioid. There is tolerance (a need for markedly increased amounts of opioid to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of opioid). There is withdrawal syndrome for opioid (see below). The individual takes opioid (or a closely related substance) to relieve or avoid withdrawal symptoms.

Withdrawal syndrome is triggered by the discontinuance or reduction in opioid use or the administration of an opioid antagonist, especially when opioid use has been heavy and prolonged. The syndrome consists in at least 3 of the following: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or sweating; diarrhea; yawning; fever; and insomnia. The signs or symptoms develop within a week after the cessation of opioid use; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition, and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance (DSM-5).

Individuals who are in withdrawal complain of muscle cramps, tremors, nausea, anxiety, difficulty sleeping, depressed mood, and/or drug cravings, sweating, diarrhea, or fever. Most withdrawal symptoms resolve within a week, but some, such as anxiety or insomnia, can last for weeks to months.

It is necessary to specify if the opioid use disorder is in early remission, or in sustained remission, as well as if the individual is on maintenance therapy, or in a controlled environment where access to opioid is restricted. It is also necessary to specify the current severity: mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms) (DSM-5).

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 (miosis), slowed speech and movement, euphoria, and/or weight loss. Drug overdose is indicated by slow, shallow respirations; unconsciousness; miosis; 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 (mydriasis), or yawning. Needle tracks or scars may be evident, usually in the arms, hands, feet, or groin areas.

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 (CBC), liver function test, electrolytes, and blood alcohol levels may be helpful. If the individual is dependent on opioids, naloxone will elicit narcotic withdrawal.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

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 individuals. 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 (a synthetic opioid that prevents or reduces the unpleasant heroin withdrawal symptoms) 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 combination of buprenorphine and naloxone may be used to block withdrawal symptoms. Naltrexone may be used to prevent relapses.

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 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, although individuals may have relapses while they are recovering (DSM-IV-TR). Some individuals never seek treatment.

Once dependence develops, it may continue over 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. Opioid 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.

Risk: Individuals with opioid dependence may be distracted by thoughts of obtaining their next dose despite a desire to stop using. Such individuals present a safety risk to themselves and their coworkers even when not actively using the drug, and should be prevented from performing safety-sensitive work tasks. Risk of recurrence may be reduced by scheduling regular yet random blood and/or urine tests to ensure compliance with the work contract, and by encouraging attendance in substance abuse treatment and support groups during the individual's personal time.

Capacity: Capacity may be impaired by obsessive thoughts over obtaining the drug, by active drug use on the job, or by symptoms associated with drug withdrawal (e.g., muscle cramps, tremors, nausea, anxiety, difficulty sleeping, depressed mood, diarrhea, fever).

Tolerance: Tolerance regarding job activities is typically not a concern with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

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

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

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

Preda, Adrian, et al. "Opioid Abuse." eMedicine. 1 Dec. 2014. Medscape. 5 May 2015 <http://emedicine.medscape.com/article/287790-overview>.

Source: Medical Disability Advisor






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