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Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.

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Chapter 4. Initial Screening, Admission Procedures, and Assessment Techniques

In This Chapter …

Initial Screening

Admission Procedures and Initial Evaluation

Medical Assessment

Induction Assessment

Comprehensive Assessment

Initial screening or intake procedures determine an applicant's eligibility and readiness for medication-assisted treatment for opioid addiction (MAT) and admission to an opioid treatment program (OTP). Ongoing assessment should begin as soon as a patient is admitted to an OTP. It provides a basis for individualized treatment planning and increases the likelihood of positive outcomes.

No single tool incorporates all the important elements for assessing patients in MAT. The Addiction Severity Index (ASI) (McLellan et al. 1992), although not comprehensive, can guide collection of the basic information needed to measure patient conditions and progress objectively. Recent research (e.g., Bovasso et al. 2001) continues to support the validity of ASI composite scores. The consensus panel recommends that OTPs develop tools and methods for more extensive assessment. This chapter describes screening and assessment procedures and important considerations that might be made during and shortly after admission to an OTP, as well as assessment techniques and considerations that are important to ongoing MAT.

Initial Screening

First Contact

The screening process begins when an applicant or family member first contacts an OTP, often via telephone or a visit to the OTP. This contact is the first opportunity for treatment providers to establish an effective therapeutic alliance among staff members, patients, and patients' families. Careful planning for and interaction with new applicants and their families contribute to positive MAT outcomes. Staff members should be prepared to provide immediate, practical information that helps potential applicants make decisions about MAT, including the approximate length of time from first contact to admission, what to expect during the admission process, and types of services offered. A brief exploration of applicants' expectations and circumstances can reveal other information they need for considering MAT.

Goals of Initial Screening

The consensus panel recommends the following goals for initial screening:

  • Crisis intervention. Identification of and immediate assistance with crisis and emergency situations (see “Screening of Emergencies and Need for Emergency Care” below)
  • Eligibility verification. Assurance that an applicant satisfies Federal and State regulations and program criteria for admission to an OTP
  • Clarification of the treatment alliance. Explanation of patient and program responsibilities
  • Education. Communication of essential information about MAT and OTP operations (e.g., dosing schedules, OTP hours, treatment requirements, addiction as a brain disease) and discussion of the benefits and drawbacks of MAT to help applicants make informed decisions about treatment
  • Identification of treatment barriers. Determination of factors that might hinder an applicant's ability to meet treatment requirements, for example, lack of childcare or transportation.

Along with these primary goals, initial screening can begin to identify other medical and psychosocial risk factors that could affect treatment, including factors related to mental disorders; legal difficulties; other substance use; and vocational, financial, transportation, and family concerns. Cultural, ethnic, and spiritual factors that affect communication and might affect treatment planning should be noted as early as possible. Staff members should obtain enough information from applicants to accommodate needs arising from any of these factors if necessary.

Screening of Emergencies and Need for Emergency Care

The consensus panel recommends that providers develop medically, legally, and ethically sound policies to address patient emergencies. Emergencies can occur at any time but are most common during induction to MAT and the acute treatment phase (see chapter 7). In particular, patients who exhibit symptoms that could jeopardize their or others' safety should be referred immediately for inpatient medical or psychiatric care. If possible, staff members who conduct initial screening and assessment should make appropriate referrals before applicants are admitted to an OTP. Identifying and assessing emergencies may require staff familiarity with the components of a mental health status examination (see “Psychosocial Assessment” below).

Suicidality

In a study of population data from the U.S. National Comorbidity Survey, a significant association was found between opioid addiction and increased risk of suicide (Borges et al. 2000). Initial screening and periodic assessments should help determine whether those indicating risks of suicide need additional services (e.g., hospitalization for protection or treatment, outpatient mental treatment, or evaluation for antidepressant medication). Exhibit 4-1 lists some indicators of suicidality. Exhibit 4-2 lists recommended responses.

Exhibit 4-1. Suicide Risk Factors

Behavioral and Circumstantial Indicators of Suicide Risk
• Talk about committing suicide
• Trouble eating or sleeping
• Drastic changes in behavior
• Withdrawal from friends or social activities
• Loss of interest in hobbies, work, or school
• Preparations for death, such as making a will or final arrangements
• Giving away prized possessions
• History of suicide attempts
• Unnecessary risk taking
• Recent severe losses
• Preoccupation with death and dying
• Loss of interest in personal appearance
• Increased use of alcohol or drugs
Expressed Emotions That May Indicate Suicide Risk
• Can't stop the pain
• Can't think clearly
• Can't make decisions
• Can't see any way out
• Can't sleep, eat, or work
• Can't get out of depression
• Can't make the sadness go away
• Can't see a future without pain
• Can't see oneself as worthwhile
• Can't get someone's attention
• Can't seem to get control

Exhibit 4-2. Recommended Responses to Indicators of Suicidality

• Be direct. Talk openly and matter-of-factly about suicide.
• Be willing to listen. Allow expressions of feelings. Accept the feelings.
• Be nonjudgmental. Don't debate whether suicide is right or wrong or feelings are good or bad. Don't lecture on the value of life.
• Get involved. Become available. Show interest and support.
• Don't dare an individual to do it.
• Don't act shocked. This puts distance between the practitioner and the individual.
• Don't be sworn to secrecy. Seek support.
• Offer hope but not glib reassurances that alternatives are available.
• Take action. Remove means, such as guns or stockpiled pills.
• Get help from persons or agencies specializing in crisis intervention and suicide prevention.

Homicidality and threats of violence

Threats should be taken seriously. For example, if an individual with knowledge of OTP procedures and schedules makes a threat, patterns of interaction between staff and this individual should be shifted. It might be necessary to change or stagger departure times, implement a buddy system, or use an escort service (National Institute for Occupational Safety and Health 1996). Counseling assignments can be changed, or patients can be transferred to another OTP.

The consensus panel recommends that OTP staff members receive training in recognizing and responding to the signs of potential patient violence. OTPs should develop policies and procedures for homicide and other violent situations. The OTP's policy on violence and threats of violence should be explained at the beginning of treatment. Emergency screening and assessment procedures should include the following:

  • Asking the patient questions specific to homicidal ideation, including thoughts, plans, gestures, or attempts in the past year; weapons charges; and previous arrests, restraining orders, or other legal procedures related to real or potential violence at home or the workplace.
  • Documenting violent incidents and diligent monitoring of these records to assess the nature and magnitude of workplace violence and to quantify risk. When a threat appears imminent, all legal, human resource, employee assistance, community mental health, and law enforcement resources should be readied to respond immediately (National Institute for Occupational Safety and Health 1996).

Admission Procedures and Initial Evaluation

After initial applicant screening, the admission process should be thorough and facilitate timely enrollment in the OTP. This process usually marks patients' first substantial exposure to the treatment system, including its personnel, other patients, available services, rules, and requirements. The admission process should be designed to engage new patients positively while screening for and assessing problems and needs that might affect MAT interventions.

Timely Admission, Waiting Lists, and Referrals

The longer the delays between first contact, initial screening, and admission and the more appointments required to complete these procedures, the fewer the applicants who actually enter treatment. Prompt, efficient orientation and evaluation contribute to the therapeutic nature of the admission process.

If a program is at capacity, admitting staff should advise applicants immediately of a waiting list and provide one or more referrals to programs that can meet their treatment needs more quickly. A centralized intake process across programs can facilitate the admission process, particularly when applicants must be referred. For example, if an applicant accepts referral to another provider, telephone contact by the originating program often can facilitate the applicant's acceptance into the referral program. If an applicant goes willingly to another program for immediate treatment but prefers admission to the original OTP, the admission process should be completed and the applicant's name added to the waiting list.

Patients who prefer to await treatment at the original site should be added to the waiting list and contacted periodically to determine whether they want to continue waiting or be referred. For individuals who are ineligible, staff should assess the need for other acute services and promptly make appropriate referrals. The consensus panel recommends that each OTP establish criteria to decide which prequalified patients should receive admission priority, especially when a program is near capacity. For example, some programs offer high-priority admission to pregnant women, addicted spouses of current patients, applicants with HIV infection or other serious medical conditions, or former patients who have tapered off maintenance medication but subsequently require renewed treatment.

Interim Maintenance Treatment

For eligible individuals who cannot be admitted to a public or nonprofit program for comprehensive maintenance services within a reasonable geographic area and within 14 days of applying, 42 Code of Federal Regulations (CFR), Part 8 § 12(j), provides for “interim maintenance treatment,” in which medication is administered to patients at an OTP for up to 120 days without formal screening or admission and with only minimal drug testing, assuming the existence of reasonable criteria at the OTP to prioritize admissions.

Denial of Admission

Denial of admission to an OTP should be based on sound clinical practices and the best interests of both the applicant and the OTP. Admission denial should be considered, for example, if an applicant is threatening or violent. Continuity of care should be considered, and referral to more suitable programs should be the rule. Due process and attention to applicant rights (see CSAT 2004b ) minimize the possibility that decisions to deny admission to an OTP are abusive or arbitrary.

Admission Team

OTPs should have qualified, compassionate, well-trained multidisciplinary teams (see chapter 6) that efficiently collect applicants' information and histories, evaluate their needs as patients, and orient them to MAT. Team members should be cross-trained in treating addiction and co-occurring disorders. Those conducting admission interviews should be culturally competent, and their interactions with applicants should not be stigmatizing. They also should be able to communicate OTP policies and services and make appropriate referrals.

Information Collection and Dissemination

Collection of patient information and dissemination of program information occur by various methods, such as by telephone; through a receptionist; and through handbooks, information packets, and questionnaires. Medical assessments (e.g., physical examinations, blood work) and psychosocial assessments also are necessary to gather specific types of information. Although collection procedures differ among OTPs, the consensus panel recommends that the following types of information be collected, documented, or communicated to patients:

  • Treatment history. An OTP should obtain a new patient's substance abuse treatment history, preferably from previous treatment providers, including information such as use of other substances while in treatment, dates and durations of treatment, patterns of success or failure, and reasons for discharge or dropout. Written consent from a patient is required to obtain information from other programs (see CSAT 2004b ). (See below for details on other components to include in this history.)
  • Orientation to MAT. All patients should receive an orientation to MAT, generally extending over several sessions and including an explanation of treatment methods, options, and requirements and the roles and responsibilities of those involved. Each new patient also should receive a handbook (or other appropriate materials), written at an understandable level in the patient's first language if possible, that includes all relevant program-specific information needed to comply with treatment requirements. Patient orientation should be documented carefully for medical and legal reasons. Documentation should show that patients have been informed of all aspects of the multifaceted MAT process and its information requirements, including (1) the consent to treatment (CSAT 2004b ), (2) program recordkeeping and confidentiality requirements (e.g., who has access to records and when, who can divulge information without patient consent [see CSAT 2004b ]), (3) program rules, including patient rights, grievance procedures, and circumstances under which a patient can be discharged involuntarily, and (4) facility safety instructions (e.g., emergency exit routes). OTPs should require patients to sign or initial a form documenting their participation in the orientation process. Also, patients must receive and sign a written consent to treatment form (see Appendix 4-A; see also CSAT 2004b ), which is kept on file by the OTP.
  • Age of applicant. Persons younger than age 18 must meet specific Federal and State requirements (at this writing, some States prohibit MAT for this group), and an OTP must secure parental or other guardian consent to start adolescents on MAT (see discussion below of exemptions from the Substance Abuse and Mental Health Services Administration's [SAMHSA's] 1-year dependence duration rule).
  • Recovery environment. A patient's living environment, including the social network, those living in the residence, and stability of housing, can support or jeopardize treatment.
  • Suicide and other emergency risks. (See above.)
  • Substances of abuse. A patient's substance abuse history should be recorded, focusing first on opioid use, including severity and age at onset of physical addiction, as well as use patterns over the past year, especially the previous 30 days. A baseline determination of current addiction should meet, to the extent possible, accepted medical criteria. Many people who are opioid addicted use other drugs and alcohol; this multiple substance use has definite implications for treatment outcomes (see “Substance Use Assessment” below and chapter 11). Therefore, screening and medical assessment also should identify and document nonopioid substance use and determine whether an alternative intervention (e.g., inpatient detoxification) is necessary or possible before an applicant is admitted to the OTP.
  • Prescription drug and over-the-counter medication use. All prescription drug and over-the-counter medication use should be identified. Procedures should be in place to determine any instances of misuse, overdose, or addiction, especially for psychiatric or pain medications. The potential for drug interactions, particularly with opioid treatment medications, should be noted (see chapter 3).
  • Method and level of opioid use. The general frequency, amounts, and routes of opioid use should be recorded. If opioids are injected, the risk of communicable diseases (e.g., HIV/AIDS, hepatitis C, endocarditis) increases. Patient reporting helps providers assess patients' substance addiction and tolerance levels, providing a starting point to prescribe appropriate treatment medication for stabilization (American Psychiatric Association 2000; Mee-Lee et al. 2001a ).
  • Pattern of daily preoccupation with opioids. A patient's daily pattern of opioid abuse should be determined. Regular and frequent use to offset withdrawal is a clear indicator of physiological dependence. In addition, people who are opioid addicted spend increasing amounts of time and energy obtaining, using, and responding to the effects of these drugs.
  • Compulsive behaviors. Patients in MAT sometimes have other impulse control disorders. A treatment provider should assess behaviors such as compulsive gambling or sexual behavior to develop a comprehensive perspective on each patient.
  • Patient motivation and reasons for seeking treatment. Prospective patients typically present for treatment because they are in withdrawal and want relief. They often are preoccupied with whether and when they can receive medication. Because successful MAT entails not only short-term relief but a steady, long-term commitment, applicants should be asked why they are seeking treatment, why they chose MAT, and whether they fully understand all available treatment options and the nature of MAT. Negative attitudes toward MAT may reduce patient motivation. However, concerns about motivation should not delay admission unless applicants clearly seem ambivalent. In such cases, treatment providers and applicants can discuss the pros and cons of MAT. The consensus panel believes that identifying and addressing concerns about and stressing the benefits of MAT as early as possible are essential to long-term treatment retention and maintaining patient motivation for treatment.
  • Patient personal recovery resources. A patient's comments also can identify his or her recovery resources. These include comments on satisfaction with marital status and living arrangements; use of leisure time; problems with family members, friends, significant others, neighbors, and coworkers; the patient's view of the severity of these problems; insurance status; and employment, vocational, and educational status. Identification of patient strengths (e.g., stable employment, family support, spirituality, strong motivation for recovery) provides a basis for a focused, individualized, and effective treatment plan (see chapter 6).
  • Scheduling the next appointment. Unless the program can provide assessment and admission on the same day, the next visit should be scheduled for as soon as possible. To facilitate an accurate diagnosis of opioid addiction and prompt administration of the initial dose of medication when other documentation of a patient's condition is unavailable, the applicant should be instructed to report to the OTP while in mild to moderate opioid withdrawal.

Medical Assessment

Medical assessment plays a substantial role in determining MAT eligibility. Some assessment tools and methods mentioned briefly in this chapter are explained further in chapter 10.

The results of medical assessment, including toxicology tests, other laboratory results, and psychosocial assessment, usually are reviewed by a program physician and then submitted to the medical director in preparation for pharmacotherapy. Programs should minimize delay in administering the first dose of medication because, in most cases, applicants will present in some degree of opioid withdrawal.

Determination of Opioid Addiction and Verification of Admission Eligibility

Federal regulations on eligibility

Federal regulations state that, in general, opioid pharmacotherapy is appropriate for persons who currently are addicted to an opioid drug and became addicted at least 1 year before admission (42 CFR, Part 8 § 12(e)). Documentation of past addiction might include treatment records or a primary care physician's report. When an applicant's status is uncertain, admission decisions should be based on drug test results and patient consultations.

Exemptions from SAMHSA's 1-year dependence duration rule

If appropriate, a program physician can invoke an exception to the 1-year addiction history requirement for patients released from correctional facilities (within 6 months after release), pregnant patients (program physician must certify pregnancy), and previously treated patients (up to 2 years after discharge) (42 CFR, Part 8 § 12(e)(3)).

A person younger than 18 must have undergone at least two documented attempts at detoxification or outpatient psychosocial treatment within 12 months to be eligible for maintenance treatment. A parent, a legal guardian, or an adult designated by a relevant State authority must consent in writing for an adolescent to participate in MAT (42 CFR, Part 8 § 12(e)(2)). Patients younger than 18 should receive age-appropriate treatments, ideally with a separate treatment track (e.g., young adult groups).

Cases of uncertainty

When absence of a treatment history or withdrawal symptoms creates uncertainty about an applicant's eligibility, OTP staff should ask the applicant for other means of verification, such as criminal records involving use or possession of opioids or knowledge of such use by a probation or parole officer. A notarized statement from a family or clergy member who can attest to an individual's opioid abuse might be feasible.

The consensus panel does not recommend use of a naloxone (Narcan®) challenge test (see chapter 5) in cases of uncertainty. Physical dependence on opioids can be demonstrated by less drastic measures. For example, a patient can be observed for the effects of withdrawal after he or she has not used a short-acting opioid for 6 to 8 hours. Administering a low dose of methadone and then observing the patient also is appropriate. Administering naloxone, although effective, can initiate severe withdrawal, which the consensus panel believes is unnecessary. It also requires invasive injection, and the effects can disrupt or jeopardize prospects for a sound therapeutic relationship with the patient. The panel recommends that naloxone be reserved to treat opioid overdose emergencies.

History and Extent of Nonopioid Substance Use and Treatment

The extent and level of alcohol and nonopioid drug use and treatment also should be determined, and decisions should be made about whether these disorders can be managed safely during MAT (see “Substance Use Assessment” below and chapter 11).

Medical History

A complete medical history should include organ system diagnoses and treatments and family and psychosocial histories. It should cover chronic or acute medical conditions such as diabetes, liver or renal diseases, sickle cell trait or anemia, and chronic pulmonary disease. Documentation of infectious diseases, including hepatitis, HIV/AIDS, tuberculosis (TB), and sexually transmitted diseases (STDs), is especially important. Staff should note patients' susceptibility to vaccine-preventable illnesses and any allergies and treatments or medications received for other medical conditions. Women's medical histories also should document previous pregnancies; types of delivery; complications; current pregnancy status and involvement with prenatal care; alcohol and drug use, including over-the-counter medications, caffeine, and nicotine, before and during any pregnancies; and incidences of sudden infant death syndrome.

Complete Physical Examination

Each patient must undergo a complete, fully documented physical examination by the program physician, a primary care physician, or an authorized health care professional under the direct supervision of the program physician, before admission to the OTP. The full medical examination, including the results of the serology and other tests, must be documented in the patient's record within 14 days following admission. States may have additional requirements, and OTPs must comply with these requirements. The examination should cover major organ systems and the patient's overall health status and should document indications of infectious diseases; pulmonary, liver, and cardiac abnormalities; dermatologic sequelae of addiction; vital signs; general appearance of head, eyes, ears, nose, throat, chest, abdomen, extremities, and skin; and physical evidence of injection drug use and dependence, as well as the physician's clinical judgment of the extent of physical dependence. Women should receive a pregnancy test and a gynecological examination at the OTP site or by referral to a women's health center. Again, the results of all tests, laboratory work, and other processes related to the initial medical examination are to be contained in the patient's file within 14 days following admission.

Laboratory Tests

Although Federal regulations no longer require OTPs to conduct a full panel of laboratory tests, some States do. The consensus panel recommends that laboratory tests include routine tests for syphilis, hepatitis, TB, and recent drug use. SAMHSA regulations stipulate “at least eight random drug abuse tests” annually per patient, performed according to accepted OTP practice (CFR 42, Part 8 § 12(f)(6)). Given that some drugs are metabolized extensively and excreted quickly, it is important that analytic procedures provide the highest sensitivity for substances of interest, such as breath testing for alcohol use.

TB testing

The risk of TB infection and disease is high among individuals involved with drugs (Batki et al. 2002). Rates of active TB among people who use substances and are HIV infected are high (Gourevitch et al. 1999), and cases of multidrug-resistant TB in this group are increasing. All patients should undergo screening and medical examination for TB every 12 months. Anergy panel tests should be administered to anergic patients (those with diminished reactivity to certain antigens). Patients who are immune system compromised might have a negative purified protein derivative test, even with active infection. A chest x ray or sputum analysis should be done if there is doubt. If a patient has a positive TB test, medical staff should treat the patient accordingly (see chapter 10) or refer him or her to a primary care clinic for treatment.

Hepatitis testing

People who inject drugs are at high risk for hepatitis virus infection (see chapter 10) and should be tested at admission to an OTP. Hepatitis A is an important liver infection that affects people who abuse drugs at higher rates than people who do not. Most patients in OTPs are seropositive for surface antigen or antibody to hepatitis B virus (HBV) core antigen, and some exhibit signs of chronic hepatitis. Any patients whose tests are negative for hepatitis A virus or HBV infection should be vaccinated for these infections at the OTP or by referral.

Hepatitis C virus (HCV) accounts for most new hepatitis cases among people who inject drugs, infects between 70 and 96 percent of this population, and is the country's leading cause of chronic liver disease (Sylvestre 2002b ). The consensus panel strongly recommends that HCV diagnosis and referral be an integral component of initial MAT assessment. Programs that do not offer onsite HCV antibody testing should provide appropriate referrals. (A simple blood test for hepatitis C antibodies is available; a positive result does not necessarily signal current infections, only that antibodies have developed.)

HIV testing

OTPs are required to provide adequate medical services, and the program sponsor must be able to document that these services are fully and reasonably available to patients. HIV testing on site or by referral, with pretest and posttest counseling, is a recommended medical service. OTPs should make HIV testing part of their medical services as recommended by the Centers for Disease Control and Prevention (2001a) Medical care and other supportive services can be offered if patients' HIV and HCV statuses are known early in treatment and monitored continuously.

Rapid HIV tests have been approved by the U.S. Food and Drug Administration (FDA) and are recommended by the U.S. Public Health Service to facilitate early diagnosis of HIV infection among at-risk populations involved in substance abuse (Centers for Disease Control and Prevention 2002a ). Rapid tests can detect antibodies to HIV in blood obtained by fingerstick or venipuncture, or in oral fluid and provide reliable and valid results in 20 minutes or less. Thus, the rapid HIV test provides a measure of exposure to HIV and requires confirmatory testing for a diagnosis of HIV infection. In studies by the manufacturer, the blood antibody test correctly identified 99.6 percent of people infected with HIV and 100 percent of those not infected, which is comparable to the results of FDA-approved enzyme immunoassays. FDA expects clinical laboratories to obtain similar results (Centers for Disease Control and Prevention 2003b ). OTPs performing rapid HIV tests should comply with the guidelines provided in SAMHSA's Rapid HIV Testing Initiative (www.samhsa.gov/HIVHep/rhti_factsheet.aspx). As a preliminary positive test, positive results should be confirmed by supplemental HIV testing. In addition, some States have other requirements for laboratory testing in general and HIV testing specifically.

STD testing

Early testing for STDs in patients receiving MAT usually is a State health requirement. Persons who inject drugs are at higher risk of STDs, primarily from increased likelihood of involvement in sex trading to finance drug use and the disinhibiting effects of psychoactive substances (Sullivan and Fiellin 2004). Therefore, all patients in MAT should receive serologic screening for syphilis and, for women and symptomatic men, genital cultures for gonorrhea and chlamydia (Sullivan and Fiellin 2004). In the early stages of admission and treatment, patients should be educated about the effects of STDs and their correlation with other communicable diseases, such as HIV/AIDS and hepatitis C, to increase patients' knowledge of the ways they can avoid these risks.

For many patients who are opioid addicted, sexual activities are intertwined with drug use behaviors (Calsyn et al. 2000b ). Documenting the sexual histories of heterosexual and lesbian, gay, and bisexual (LGB) patients, in terms of timing of sexual encounters and partners, is essential to determine their potential exposure to HCV, HIV, and other STDs, as well as the risk of infection for other sexual partners. Several studies have pointed to increased high-risk sexual behavior among populations that are substance addicted, homeless, and mentally ill, in addition to higher levels of psychological distress and psychiatric symptoms (McKinnon et al. 2002; Stoskopf et al. 2001).

Additional drug testing

After initial drug testing, subsequent assessment should include further review of urine, blood, oral fluid, or other drug test results. Ideally, drug tests should be conducted regularly and randomly during treatment. The first test is especially important because it is part of the initial evaluation and may serve as documentation of current opioid use. As noted in Federal regulations, the presence of opioids in test results does not establish a diagnosis of opioid addiction, and the absence of opioids does not rule it out. Clinical examination and an applicant's medical history are keys to determine the appropriateness of MAT. Chapter 9 discusses drug-testing procedures and Federal regulations governing these procedures.

Women's Health

Women in MAT should receive information on their particular health needs, for example, family planning, gynecological health, and menopause (see the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women [CSAT forthcoming f]). Women of childbearing age should be counseled on pregnancy testing during admission before making decisions about detoxification (42 CFR, Part 8 § 12(e)(3)). Pregnancy testing, along with onsite access to or referral for family planning services, should be available in all OTPs as part of an overall women's health initiative (see chapter 13).

Induction Assessment

Induction is the riskiest stage of MAT (see chapter 5), and proper medical assessment during induction requires an understanding of the pharmacology of treatment medication (see chapter 3). A patient should be assessed at least daily during induction for signs of overmedication or undermedication, and dose adjustments should be made accordingly.

Comprehensive Assessment

Completion of induction marks the beginning of stabilization and maintenance treatment and ongoing, comprehensive medical and psychosocial assessment conducted over multiple sessions. This assessment should include, but not be limited to, patient recollections of and attitudes about previous substance abuse treatment; expectations and motivation for treatment; level of support for a substance-free lifestyle; history of physical or sexual abuse; military or combat history; traumatic life events; and the cultural, religious, and spiritual basis for any values and assumptions that might affect treatment. This information should be included in an integrated summary in which data are interpreted, patients' strengths and problems are noted, and a treatment plan is developed (see chapter 6) that matches each patient to appropriate services.

Data should be collected in a respectful way, taking into consideration a patient's current level of functioning. Motivational interviewing techniques (Miller and Rollnick 2002) can help engage applicants early. The information collected depends on program policies, procedures, and treatment criteria; State and Federal regulations; and the patient's stability and ability to participate in the process. The psychosocial history can reveal addiction-related problems in areas that might be overlooked, such as strengths, abilities, aptitudes, and preferences. Most information can be analyzed by using standardized comprehensive assessment instruments tailored to specific populations or programs, such as those described by Dodgen and Shea (2000).

SAMHSA regulations require that patients “accepted for treatment at an OTP shall be assessed initially and periodically by qualified personnel to determine the most appropriate combination of services and treatment” (42 CFR, Part 8 § 12(f)(4) [Federal Register 66(11):1097]). Treatment plans should be reviewed and updated, initially every 90 days and, after 1 year, biannually or whenever changes affect a patient's treatment outcomes. Ongoing monitoring should ensure that services are received, interventions work, new problems are identified and documented, and services are adjusted as problems are solved. Patients' views of their progress, as well as the treatment team's assessment of patients' responses to treatment, should be documented in the treatment plan.

Patient Motivation and Readiness for Change

Patient motivation to engage in MAT is a predictor of early retention (Joe et al. 1998) and is associated with increased participation, positive treatment outcomes, improved social adjustment, and successful treatment referrals (CSAT 1999a ).

Starting with initial contact and continuing throughout treatment, assessment should focus on patient motivation for change (CSAT 1999a ). OTP staff members help patients move beyond past experiences (e.g., negative relationships with staff, inadequate dosing) by focusing on making a fresh start, letting go of old grievances, and identifying current realities, ambivalence about change, and goals for the future. It often is helpful to enlist recovering patients in motivational enhancement activities. TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999a ), provides extensive information about stages of change, the nature of motivation, and current guidelines for enhancing patient motivation to change.

Substance Use Assessment

As discussed previously, a patient's lifetime substance use and treatment history should be documented thoroughly. The following areas should be assessed:

  • Periods of abstinence (e.g., number, duration, circumstances)
  • Circumstances or events leading to relapse
  • Effects of substance use on physical, psychological, and emotional functioning
  • Changing patterns of substance use, withdrawal signs and symptoms, and medical sequelae.

Reports of psychiatric symptoms during abstinence help treatment providers differentiate drug withdrawal from mental disorder symptoms and can reveal important clues to effective case management, for example, the need to refer patients for treatment of co-occurring disorders.

Chapter 11 discusses treatment methods and considerations for patients with histories of multiple substance abuse. Most of these patients fall into one of three groups, which should be determined during assessment: those who use multiple substances (1) to experience their psychoactive effects, (2) to self-medicate for clinically evident reasons (e.g., back pain, insomnia, headache, co-occurring disorders), or (3) to compensate for inadequate treatment medication (Leavitt et al. 2000). Multiple substance use should be identified and addressed as soon as possible because of the risk of possible overdose for patients who continue to abuse drugs or alcohol during treatment. Continued substance abuse while in MAT might indicate that another treatment option is more appropriate. A challenge in treating patients who abuse substances for clinically evident reasons is to determine whether the patients are attempting to medicate undiagnosed, misdiagnosed, or undertreated problems. If so, then effectively addressing these related problems may reduce or eliminate continuing drug or alcohol abuse and improve outcomes.

Cultural Assessment

A comprehensive assessment should include patients' values and assumptions; linguistic preferences; attitudes, practices, and beliefs about health and well-being; spirituality and religion; and communication patterns that might originate partly from cultural traditions and heritage (Office of Minority Health 2001). Staff knowledge about diverse groups is important for effective treatment services. Of particular importance are experiences and coping mechanisms related to assimilation and acculturation of groups into mainstream American culture that may affect how they perceive substance abuse and MAT. Gathering pertinent information often must rely on subjective sources (e.g., interviews and questionnaires). Even so, staff members involved in screening and assessment should be cautioned against making value judgments about cultural or ethnic preferences or assumptions about “average” middle-class American values and beliefs. (See the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT forthcoming b].)

A shared staff—patient cultural identity is attractive to some patients entering treatment. To the extent possible, patient preferences for staff members who share their cultural identity should be honored. Multilingual educational materials and displays of culturally diverse materials in the OTP help patients feel more at ease when English is not their primary language.

Psychosocial Assessment

The components and objectives of psychosocial assessment also are applicable to patients in MAT. A psychosocial assessment typically identifies the relevant dynamics of patients' lives and functioning both before the onset of illness (e.g., depression, anxiety) and currently. It identifies patients' specific strengths and resources (e.g., employment, supportive family relationships) as a basis for focused, individualized, effective treatment planning.

History of co-occurring disorders and current mental status

Mental status assessments identify the threshold signs of co-occurring disorders and require familiarity with the components of a mental status examination (i.e., general appearance, behavior, and speech; stream of thought, thought content, and mental capacity; mood and affect; and judgment and insight) as outlined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association 2000). A mental status assessment also should look for perceptual disturbances and cognitive dysfunction.

Qualified professionals should train all staff members involved in screening and assessment to recognize signs and symptoms of change in patients' mental status. This training should be ongoing. After reviewing their observations with the program physician, staff members should refer all patients still suspected of having co-occurring disorders for psychiatric evaluation. This evaluation should identify the types of co-occurring disorders and determine how they affect patients' comprehension, cognition, and psychomotor functioning. Persistent neuropsychological problems warrant formal testing to diagnose their type and severity and to guide treatment. Consultations by psychologists or physicians should be requested or referrals made for testing. (See chapter 12 for typical methods of psychiatric screening and diagnosis in an OTP.)

Sociodemographic history

Sociodemographic data about an applicant should include employment, educational, legal, military, family, psychiatric, and medical histories, as well as current information, and should be supplemented by documents for identification, such as a driver's license, birth or baptismal certificate, passport, Social Security card, Medicaid card, public assistance card, or identification card from another substance abuse treatment program.

Family and cultural background, relationships, and supports

The effect of substance use on a patient's family cannot be overestimated, and family problems should be expected for most patients entering treatment. The comprehensive assessment should include questions about family relationships and problems, including any history of domestic violence, sexual abuse, and mental disorders (see below). When possible, the assessment should include input from relatives and significant others. Because families with members who abuse substances have problems directly linked to this substance abuse, at least one staff member should be trained in family therapy or in making appropriate referrals for this intervention.

During assessment, program staff should be sensitive to various family types represented in the patient population. For example, programs treating significant numbers of single parents should consider onsite childcare programs. Structured childcare services also enable OTP staff to observe and assess a patient's family functioning, which can be valuable in treatment planning.

Any counselor or treatment provider who might confront emergencies related to child or spousal abuse should be trained in how to identify and report these problems. TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b ), provides screening, assessment, and response guidance when domestic violence is suspected. TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000d ), focuses on screening and assessment when patients are suspected of being past victims or perpetrators of child abuse. Staff members should be trained to listen and prepared to hear traumatic stories and handle these situations, for example, by monitoring any intense symptoms and seeking special assistance when necessary (CSAT 2000d ). Staff should be able to identify individuals who exhibit certain signs and symptoms associated with abuse (e.g., posttraumatic stress disorder [PTSD]) and provide or coordinate immediate services to address it (CSAT 1997b , 2000d ).

Child abuse. All States require mandatory reporting of child abuse by helping professionals including OTP staff—particularly State-licensed physicians, therapists, nurses, and social workers (CSAT 2000d ). Most States require that this reporting be immediate and offer toll-free numbers. Most also require that reports include the name and address of a parent or caretaker, the type of abuse or neglect, and the name of the alleged perpetrator. Failure to report indications of abuse that results in injury to a child can lead to criminal charges, a civil suit, or loss of professional licensure. Mandated reporters generally are immune from liability for reports made in good faith that later are found to be erroneous (CSAT 2000d ).

Staff members who suspect domestic violence should investigate immediately whether a patient's children have been harmed. Inquiries into possible child abuse can occur only after notice of the limitations of confidentiality in MAT (42 CFR, Part 8 § 12(g)) has been given to the patient, who must acknowledge receipt of this notice in writing. Patients also must be informed, during orientation and when otherwise applicable, that substance abuse treatment providers are required to notify a children's protective services agency if they suspect child abuse or neglect.

Spousal or partner abuse. Generally, if a patient believes that she or he is in imminent danger from a batterer, the treatment provider should respond to this situation before addressing any others and, if necessary, suspend the screening or assessment interview to do so. Exhibit 4-3 summarizes the steps a treatment provider should follow. He or she should refer a patient to a shelter, legal services, or a domestic violence program if indicated. Providers should be familiar with relevant Federal, State, and local regulations on domestic violence (e.g., the 1994 Violence Against Women Act [visit www.ojp.usdoj.gov/vawo/laws/vawa/vawa.htm]) and the legal resources available (e.g., restraining orders, duty to warn, legal obligation to report threats and past crimes, confidentiality).

Exhibit 4-3. Recommended Procedures for Identifying and Addressing Domestic Violence*

• Look for physical injuries, especially patterns of untreated injuries to the face, neck, throat, and breasts, which might become apparent during the initial physical examination.
• Pay attention to other indicators: history of relapse or treatment noncompliance; inconsistent explanations for injuries and evasiveness; complications in pregnancy; possible stress- and anxiety-related illnesses and conditions; sad, depressed affect; or talk of suicide.
• Fulfill legal obligations to report suspected child abuse, neglect, and domestic violence.
• Never discuss a patient without the patient's permission; understand which types of subpoenas and warrants require that records be turned over to authorities.
• Convey that there is no justification for battering and that substance abuse is no excuse.
• Contact domestic violence experts when battery has been confirmed.
*

State laws may include other requirements.

Romans and colleagues (2000) identified the following methods for exploring potential domestic violence situations, which can be incorporated into effective assessment tools:

  • Always interview patients in private about domestic violence.
  • Begin with direct, broad questions and move to more specific ones; inquire how disagreements or conflicts are resolved (e.g., “Do you want to hit [him or her] to make [him or her] see sense?”); ask whether patients have trouble with anger or have done anything when angry that they regret; combine these questions with other types of lifestyle questions.
  • Ask about violence by using concrete examples and specific hypothetical situations rather than vague, conceptual questions.
  • Display information about domestic violence in public (e.g., waiting room) and private (e.g., restroom) locations.
  • Use opportunities during discussions (e.g., comments about marital conflict situations or poor communication with partners) to probe further.
  • Obtain as complete a description as possible of the physical, sexual, and psychological violence perpetrated by or on a patient recently; typically, those who commit domestic violence minimize, deny, or otherwise obscure their acts.

History of physical or sexual abuse

Some patients enter an OTP with a history of physical or sexual abuse, which frequently causes additional psychological distress (Schiff et al. 2002). Information about these types of abuse is important in treatment planning but not always easily accessible using specific assessment tools, especially early in treatment. Some patients with abuse histories might deny their victimization. Many women are less likely to admit abuse to male counselors. Male staff should know when to request a staff change for counseling about physical or sexual abuse. Patients might not be ready to address the problem, think it is unrelated to substance abuse, or be ashamed. Gathering information from them about abuse, therefore, requires extreme care and respect during screening and assessment. Once patients are stabilized and their practical needs are addressed, counseling by qualified treatment providers can focus on this problem.

Peer relations and support

The extent of social deterioration, interpersonal loss, and isolation that patients have experienced should be documented thoroughly during screening and assessment. Assessment of a patient's support systems, including past participation in mutual-help groups (e.g., Alcoholics Anonymous, Methadone Anonymous [MA]), is critical to identifying peer support networks that provide positive relationships and enhance treatment outcomes. Some 12-Step groups are ill-informed about MAT and may be unaware of the treatment goals of MAT and less than supportive; in these cases, providers should help patients identify other sources of support (e.g., MA groups) and encourage continued development of some type of peer support network. In areas with limited resources, patients may be able to overcome initial discriminatory behavior in existing groups by increasing their knowledge of MAT and their ability to self-advocate.

Housing status and safety concerns

Based on year 2000 estimates, approximately 10 percent of patients in MAT are homeless or living as transients when admitted to treatment (Joseph et al. 2000). Moreover, those who are not homeless often live with people who are addicted or in areas where substance use is common. In the opinion of the consensus panel, early intervention to arrange safe, permanent shelter for these patients should be a high priority, and a patient's shelter needs should be ascertained quickly during screening and assessment. OTPs should establish special support services to help patients secure appropriate living arrangements, such as referral agreements with housing agencies or other programs to locate housing that addresses the special needs of homeless patients.

Criminal history and legal status

Another purpose of screening and assessment is to identify legal issues that might interrupt treatment, such as outstanding criminal charges or ongoing illegal activity to support substance use; however, pending or unresolved charges are not a contraindication for MAT. Assessment may involve exploring personal circumstances such as child custody and related obligations. In the consensus panel's experience, many patients ignore legal problems during periods of substance use, but these problems pose a serious threat to recovery. In addition, a patient's arrest record, including age at first arrest, arrest frequency, nature of offenses, criminal involvement during childhood, and life involvement with the criminal justice system, should be clarified.

Insurance status

Patients' resources to cover treatment costs should be determined during screening and assessment. Often they are uninsured or have not explored their eligibility for payment assistance. The consensus panel believes that OTPs are responsible for helping patients explore payment options so that they have access to a full range of treatment services, including medical care, while ensuring payment to the OTP.

In situations of inadequate funding or patient ineligibility for funds, another source of payment should be identified. OTP staff can assist patients in applying for public assistance or inquiring whether personal insurance will reimburse MAT costs. Counselors can help patients make decisions about involving their insurance companies and address fears that employers will find out about their substance use or that benefits for health care will be denied.

Employment history

Another important component of psychosocial assessment is a patient's employment history. Based on year 2000 estimates, only 20 percent of patients in MAT were employed when admitted to an OTP (Joseph et al. 2000). Until they are stabilized, employed patients often experience substance-related difficulties at the workplace, including lack of concentration, tardiness and absences, inability to get along with coworkers, on-the-job accidents, and increased claims for workers' compensation. Early identification of these difficulties can help staff and patients create a more effective treatment plan.

Patients who are employed often are reluctant to enter residential treatment or take the time to become stabilized on medication; however, most of these patients would take medical or other leave time if they were hospitalized for other illnesses, and they should be encouraged to take their addiction as seriously. A physician's note recommending time off work for some period might help, but it should be on letterhead that does not reference drug treatment.

Military or other service history

A patient's military or other service history can highlight valuable areas in treatment planning. In particular, was military service generally a positive or negative experience? If the former, treatment providers can help patients identify areas of strength or personal achievement, such as the ability to cope under stress, receipt of medals for service accomplishments, and honorable discharge; patients can learn to build on past strengths in current challenging situations and to progress in treatment. If the latter, providers should review patients' negative military experiences, including loss of friends and loved ones, onset of substance use, war-related injuries, chronic pain, PTSD, and co-occurring disorders (e.g., depression). This information might indicate patterns of behavior that continue to affect recovery.

Patients' military history also might reveal their eligibility for medical and treatment resources through U.S. Department of Veterans Affairs programs and hospitals or social service agencies.

Spirituality

“Spirituality” in this TIP refers to willing involvement in socially desirable activities or processes that are beyond the immediate details of daily life and personal self-interest. Attention to the ethics of behavior, consideration for the interests of others, community involvement, helping others, and participating in organized religion are expressions of spirituality.

A patient's spirituality can be an important treatment resource, and persons recovering from addiction often experience increased interest in the spiritual aspects of their lives. A study by Flynn and colleagues (2003) of 432 patients admitted to 18 OTPs found that those who remained in recovery for 5 years credited religion or spirituality as one factor in this outcome. Staff should assess patients' connections with religious institutions because these institutions often provide a sense of belonging that is valuable in the rehabilitative process.

Miller (1998) found a lack of research exploring the association between spirituality and addiction recovery but concluded that spiritual engagement or reengagement appeared to be correlated with recovery. In studies reviewed by Muffler and colleagues (1992), individuals with a high degree of spiritual motivation to recover reported that treatment programs that included spiritual guidance or counseling were more likely to produce positive outcomes than programs that did not. OTPs should assess spiritual resources adequately. Counselors and other mental health professionals could benefit from training in patient spirituality if it is difficult for them to explore.

Sexual orientation and history

The assessment and treatment needs of heterosexual and LGB populations are similar and should focus on stopping the substance abuse that interferes with patients' well-being. Assessment of risk factors associated with sexual encounters and partners is essential. What often differs for an LGB population is the importance of assessing patients' sexual or gender orientation concerns, such as their feelings about their sexual orientation (CSAT 2001b ). OTP staff should pay strict attention to confidentiality concerns for LGB patients because they may be at increased risk of legal or other actions affecting employment, housing, or child custody. Treatment modalities and programs should be accessible to all groups, and programs providing ancillary services should be sensitive to the special needs of all patients regardless of sexual orientation (CSAT 2001b ).

Patients' ability to manage money

Financial difficulties are common among patients in MAT, who often have spent considerable money on their substance use that otherwise would have paid for rent, food, and utilities. Financial status and money management skills should be assessed to help patients understand their fiscal strengths and weaknesses as they become stabilized. Patients often need assistance to adjust to loss of income caused by reduced criminal activity and develop skills that enhance their legitimate earning power. Once financial factors are clarified, patients may be better prepared to devise realistic strategies to achieve short- and long-term goals.

Recreational and leisure activities

Recreational and leisure activities are important in recovery; therefore, assessment should determine any positive activities in which patients have participated before or during periods of substance use. Identifying existing recreational and leisure time preferences and gaining exposure to new ones can be significant steps in developing a recovery-oriented lifestyle.

Appendix 4-A. Example of Standard Consent to Opioid Maintenance Treatment

CONSENT TO PARTICIPATION IN OPIOID PHARMACOTHERAPY TREATMENT

Patient's Name: ________________________________ Date: _________________________

I hereby authorize and give voluntary consent to the Division and its medical personnel to dispense and administer opioid pharmacotherapy (including methadone or buprenorphine) as part of the treatment of my addiction to opioid drugs. Treatment procedures have been explained to me, and I understand that this will involve my taking the prescribed opioid drug at the schedule determined by the program physician, or his/her designee, in accordance with Federal and State regulations.

It has been explained that, like all other prescription medications, opioid treatment medications can be harmful if not taken as prescribed. I further understand that opioid treatment medications produce dependence and, like most other medications, may produce side effects. Possible side effects, as well as alternative treatments and their risks and benefits, have been explained to me.

I understand that it is important for me to inform any medical provider who may treat me for any medical problem that I am enrolled in an opioid treatment program so that the provider is aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my opioid pharmacotherapy or my chances of successful recovery from addiction.

I understand that I may withdraw voluntarily from this treatment program and discontinue the use of the medications prescribed at any time. Should I choose this option, I understand I will be offered medically supervised tapering.

For Female Patients of Childbearing Age: There is no evidence that methadone pharmacotherapy is harmful during pregnancy. If I am or become pregnant, I understand that I should tell my medical provider right away so that I can receive appropriate care and referrals. I understand that there are ways to maximize the healthy course of my pregnancy while I am in opioid pharmacotherapy.

_____________________________________ _________________________ ____________

Signature of Patient                                                  Date of Birth                                   Date

Witness: _______________________________________________________________________

Adapted with permission from Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Division of Substance Abuse, Bronx, NY.

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