Screening and diagnosis

Description: 
This Clinical Practice Guideline is intended to provide primary care clinicians and other healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with substance use disorders (SUD), leading to improved clinical outcomes. (From the website.)
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Department of Veterans Affairs and Department of Defense
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Description: 
This step-by-step guide provides medical professionals a clear clinical plan from patient history intake to follow-up visit after administering XR-Naltrexone injections.
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Some patients are better suited than others for buprenorphine treatment. Additionally, some patients are more challenging than others, either due to complicated medical or psychiatric issues, or problematic behaviors.

When first starting your buprenorphine practice, you may want to treat "easier" patients until you feel 100% comfortable with the induction and stabilization processes. Use a checklist and/or treatment screening form to assess patients before initiating treatment.

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Description: 
Aids physicians in screening patients for opioid use disorders. Included are examples of screening instruments, recommendations of laboratory tests to complete, and medical disorders related to substance abuse.
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Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 

Over 40% of opioid dependent individuals have co-occuring psychiatric disorders. The most common are depression, anxiety disorders, and bipolar disorder.

Psychiatric comorbidities may complicate buprenorphine treatment in terms of treatment priorities, stabilization concerns, and medication interactions. To make a sound treatment decision, you need to distinguish between independent and substance-induced disorders using the criteria below:

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Description: 
This document describes how to manage medications for co-occuring psychiatric disorders in a patient receiving buprenorphine.
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Physician Clinical Support System (PCSS)
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Description: 
Provides physicians with information on how to work with a patient who has co-occurring disorders, including how to engage the patient in treatment and how to develop a successful therapeutic relationship.
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Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 
Description: 
This chapter of TIP 43 discusses the prevalence, etiology, screening, diagnosis, and treatment of psychiatric disorders that co-occur with opioid addiction.
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Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 
Description: 
This set of guidelines aids physicians in providing detoxification and substance abuse treatment, specifically examining co-occurring medical and psychiatric conditions.
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Substance Abuse and Mental Health Services Administration (SAMHSA)
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Medical complications can result from the opioid itself, as well as from the way it is administered. The main medical complications among the opioid-dependent population are related to injecting heroin.

View ReferencesHide References
Kleber H, Weiss R, Anton R, et al. Practice guideline for the treatment of patients with substance use disorders, 3rd edition. American Psychiatric Association. 2010. Available at: http://www.guideline.gov/content.aspx?id=24158 Accessed on: 2015-06-30.
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Description: 
This publication discusses the medical co-management of hepatitis infection and opioid abuse.
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Center for Substance Abuse Treatment (CSAT)
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Description: 
Discussing the psychosocial aspects of treatment in patients receiving Buprenorphine/Naloxone
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Physician Clinical Support System (PCSS-MAT)
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Description: 
Guideline document discussing interactions between buprenorphine and HIV medication.
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Physician Clinical Support System (PCSS)
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Description: 
This chapter of TIP 43 is aimed to help treatment providers identify co-occurring medical problems in patients who are addicted to opioids.
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Substance Abuse and Mental Health Association (SAMHSA)
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Physician stage in practice: 

Many SubstancesPatients with opioid use disorders commonly have problems with other substances as well; in fact, polysubstance abuse is considered the norm rather than the exception (Patrick, 2003).

Among opioid addicts, cocaine and alcohol are the most frequently abused substances (Strain, 2002). Many also commonly misuse other prescription medications.

View ReferencesHide References
Patrick, D. Dual diagnosis: substance-related and psychiatric disorders. The Nursing Clinics of North America. 2003; 38: 67-73.
Strain EC. Assessment and treatment of comorbid psychiatric disorders in opioid-dependent patients. Clin J Pain. 2002; 18(4 Suppl): S14-27.
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Description: 
This website offers comprehensive guidelines for treating patients who have substance use disorders.
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American Psychiatric Association (APA), 2006
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Physician stage in practice: 

Urine Testing in Buprenorphine Treatment

Description: 
Information on the logistics of urine testing, including the timing of testing, frequency, location, and test type.

Being able to accurately gauge the current drug use by patients enrolled in a substance abuse program is essential; self-reports, family member reports, observation of attitude alteration, and behavior changes are generally insufficient. Therefore, urine testing is an integral part of the office-based buprenorphine treatment program and should be explained as such to patients during the initial discussion of the treatment rules and expectations. Patients must understand that this, too, is an ongoing part of their treatment.

Considerations

Because it is an ongoing part of buprenorphine treatment, the provider must make several fundamental decisions about urine testing procedures.

Timing of Testing

A plan for urine testing must include a decision between random and scheduled testing. Random testing dramatically increases the probability of detecting illicit drug usage: Patients can no longer plan their drug usage around a testing schedule. A possible method of implementing random testing may require patients to call the office on scheduled days to ascertain whether that particular day will be a testing day.

Frequency of Testing

The provider must also consider the frequency of testing. In methadone maintenance programs, more frequent testing provides a more complete picture of drug use habits, thus helping to direct treatment (Wasserman et al., 1999). SAMHSA (2004) recommends administering monthly urine tests to patients being treated for opioid dependence. These tests should screen not only for continued opioid use but also for use of other illicit drugs (SAMHSA, 2004).

Collection Methods

Collection monitoring is an important consideration in urine testing -- direct observation is the most definite mechanism of observation. By requiring the patient to leave coats, purses, etc., outside the bathroom and having a same-sex observer present, the chances of obtaining a doctored sample are minimized. If direct observation is not desired or possible, thermometers or testing machines that analyze urine temperature are an appropriate substitute. If patients have a substantial commute, providers may consider testing the patient in a location outside the office, although similar monitoring considerations must be taken into account at collection times. To prevent patients from tampering with their samples using available materials, collection facilities could lack soap dispensers and cleaning agents (NIDA, 1986). If dilution of urine is a concern, consider dyeing toilet water or installing a chemical toilet (NIDA, 1986).

On-Site Versus Off-Site Testing

Providers must decide whether on-site or off-site urine testing is the more appropriate choice for their treatment program. Each has its advantages. Advantages of on-site testing include less handling of the specimen, which will reduce the potential for mistakes, a "greater sense of confidentiality," and quicker results (NIDA, 1986). However, in most cases, a positive result should be confirmed using a different testing technique at an off-site laboratory (NIDA, 1986). Advantages of off-site testing include immediate access to additional tests to confirm a positive initial result, which also decreases potential mistakes, and expertise of the laboratory staff (NIDA, 1986). If testing is to be done off-site, specimens should be stored in a secure (locked) location until they are shipped (NIDA, 1986). Regardless of where analysis is done, be sure to secure all sampling accoutrements, such as cups, lids, and labels.

Test Type

Urine testing for opioids can be done either by immunoassay or by laboratory-based, drug-specific identification using gas chromatography, mass spectrometry, high-phase liquid chromatography, or a similar technique. Immunoassays are fast, easy to use, and reliably detect any natural opioids (codeine, morphine, heroin) that are present. However, immunoassays often do not detect semisynthetic (oxycodone, buprenorphine) and synthetic (fentanyl) opioids (Gourlay et al., 2002). While methadone is a synthetic opioid, immunoassays have been developed specifically to detect it (SAMHSA, 2004). Drug-specific identification is more time consuming and detects only one drug per test, but it is reliable for all drugs (Gourlay et al., 2002).

Description: 
Drinking too much? Test yourself and your own use or abuse of alcohol with this 22-question quiz. Focusing specifically on alcohol use, this self-test does not address the use of other drugs.
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Counseling Resource
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Description: 
Concerned about your use — or abuse — of drugs? With 20 questions, this simple self-test may help you identify aspects of your drug use which could be problematic. This test specifically does not include alcohol use.
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Counselling Resource
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CAGE-AID

Description: 
Screening test for alcohol and drugs.

One of the most commonly used standardized screening tools for detecting drug use problems is the CAGE-AID, a variation on the CAGE instrument that was originally created to screen for alcohol use. Brown et al., (1998) modified the CAGE questionnaire to add screening for drug use (AID stands for "adapted to include drugs"). The authors were able to obtain 70.9% sensitivity and 75.7% specificity with this modified scale.

Each letter in the acronym CAGE represents one question in the 4-item scale:

C Cut down -- Have you ever felt you ought to cut down on your drinking or drug use?
A Annoyed -- Have people annoyed you by criticizing your drinking or drug use?
G Guilty -- Have you ever felt bad or guilty about your drinking or drug use?
E Eye-opener -- Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
Description: 
The Alcohol Use Disorders Identification Test, or AUDIT, is comprised by ten questions that ask about the frequency and amount of alcohol consumption, the ramifications of the patient's drinking, and the concern of others for the patient's behavior.Patients are to be presented the form so that they can circle answers for each question. The AUDIT takes about 3 minutes to administer and score.
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https://www.sbirttraining.com
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Description: 
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) is a semi-structured interview for making the major DSM-IV Axis I diagnoses. The SCID-II is a semi-structured interview for making DSM-IV Axis II: Personality Disorder diagnoses. In addition to the important distinction between the SCID-I and SCID-II, there are several different versions and editions of the SCID.
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DSM Structured Clinical Interview
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In many patients, you will able to identify opioid withdrawal by observing the patient and through physical exam.

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DSM-5 Criteria for Opioid Withdrawal

Description: 
Lists DSM-5 Criteria for Opioid Withdrawal

Opioid withdrawal occurs in opioid-dependent individuals who reduce or stop their opioid use or who take an opioid antagonist (precipitated withdrawal). Because of its high affinity but low activity at opioid receptors, buprenorphine can act as an antagonist in some patients.

DSM-5 Criteria for Opioid Withdrawal


A. Either of the following:

  • cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)
  • administration of an opioid antagonist after a period of opioid use


B. Three (or more) of the following, developing within minutes to several days after Criterion A:

  • dysphoric moods
  • nausea or vomiting
  • muscle aches
  • lacrimation or rhinorrhea
  • pupillary dilation, piloerection, or sweating
  • diarrhea
  • yawning
  • fever
  • insomnia

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not due to another medical condition and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance.

The ICD-10-CM code with moderate of severe opioid use disorder is F11.23. (Do not use withdrawal code with mild opioid use disorder.) The ICD-9 CM code was 292.0.

(Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. Copyright © 2000 American Psychiatric Association.). Updated to: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
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Patient Handouts: 
Description: 
The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater.
Source: 
Reprinted from Handelsman, L., Cochrane, K. J., Aronson, M. J., et al. (1987) Two new rating scales for opiate withdrawal. American Journal of Drug and Alcohol Abuse, 13 (3), 293–308. By courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Description: 
The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely).
Source: 
Reprinted from Handelsman et al. 1987, p. 296, by courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Opioid Use Disorder Criteria:

A minimum of 2-3 criteria is required for a mild substance use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013). Opioid Use Disorder is specified instead of Substance Use Disorder, if opioids are the drug of abuse. Note: A printable checklist version is linked below

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Description: 
The APA's breakdown on changes to substance-related addictive disorder diagnoses introduced by DSM-5. The document goes over substance use disorder, addictive disorders and briefly states the APA's position on caffeine use disorder.
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APA DSM-5
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Description: 
Describes the substance use disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
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Substance Abuse and Mental Health Services Administration (SAMHSA)
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Physician stage in practice: 
Description: 
Brief critique and explanation of the changes in terminology and classification for substance use disorder as described in DSM-5. The author highlights the impact of the changes in vocabulary as well as the potential fallacies created by them.
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Join Together
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Description: 
Form for use in the clinic to support evaluation for possible opioid use disorder based on DSM-5 diagnostic criteria.
Source: 
APA
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Commonly Used Forms: 

Many patients who abuse opioids will not have any obvious physical symptoms. However, there are some signs to look for during the physical exam.

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Description: 
Photograph classification system for identifying skin lesions of injection drug users.
Source: 
Substance Abuse and Mental Health Administration (SAMHSA)
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