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.

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).

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.

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.

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).

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.