In simple words: This code indicates that a person has an opioid addiction without any additional complications like severe intoxication, mental health issues, or sexual problems.

Uncomplicated opioid dependence refers to a pattern of opioid use leading to clinically significant impairment or distress.The individual exhibits a compulsive need to use opioids, develops tolerance (requiring increased amounts to achieve the desired effect), and experiences withdrawal symptoms upon cessation or dose reduction. This diagnosis excludes cases where there are complications such as intoxication with delirium, mood disorders, psychoses, sexual dysfunction, or other disorders.

Example 1: A 35-year-old patient presents with a history of prescription opioid use for chronic back pain. They now report needing higher doses for pain relief and experience withdrawal symptoms when they try to stop. They are not currently experiencing any other mental health disorders or complications., A 28-year-old patient admits to using heroin regularly. They acknowledge a strong craving for the drug, increased tolerance, and withdrawal symptoms upon cessation.They deny any current mental health or other substance use disorders., A 45-year-old individual, on long-term methadone maintenance therapy for opioid dependence, consistently attends therapy sessions and adheres to the treatment plan. They do not meet the criteria for opioid use disorder except tolerance to methadone.

Documentation should include evidence of opioid dependence such as: patient self-report of opioid craving, increasing tolerance, withdrawal symptoms; physical examination findings; laboratory test results confirming opioid use; and a detailed history of the substance use including quantity, frequency, duration, and route of administration.