DSM 5 Opioid Use Disorder Checklist

Patient’s Name:

Date of Birth:

Worksheet for DSM-5 criteria for diagnosis of Opioid Use Disorder

Diagnostic Criteria

(Opioid Use Disorder requires at least 2 criteria be met within a 12 month period)
Meets criteria?

Yes OR No
Notes/Supporting information
1. Opioids are often taken in larger amounts or over a longer period of time than intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4. Craving, or a strong desire to use opioids.
5. Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7. Important social, occupational or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.
10. *Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of an opioid
11. *Withdrawal, as manifested by either of the following:

(a) the characteristic opioid withdrawal syndrome

(b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms

*This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Severity: Mild: 2-3 symptoms, Moderate: 4-5 symptoms. Severe: 6 or more symptoms.

Signed___________________________________________Date_______________________

Criteria from American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American Psychiatric Association page 541.