Screening and Diagnosis

Many of the patients you treat with MOUD may come from outside referrals. You can cultivate a relationship with providers and organizations in your community which, combined with the low threshold quick access to appointments and medications, may be more effective than screening for patients in your practice.¹ See Care Coordination and Patient Referral Sources for more information.

Screen patients who report opioid use to assess for misuse and to determine which of your patients uses non-prescribed opioids. This may already be part of your standard practice of updating their list of medications and other substances used. This can be done through clinical discussions or by using a validated screening tool.

Ideally, decide which standardized screening tools to use and determine how to incorporate screening into your patient workflow. These tools may be self-administered online or on paper, or they may be administered by staff. For tools requiring staff administration, it may be more efficient to have nurses or clinical assistants handle the process. Many of these screeners also detect other substances with misuse potential. Selected screening tools are listed under the Resources section.

Symptoms of opioid misuse include:

• Intoxication: Drowsiness, constricted pupils, slurred speech, impaired memory, and changes in mood.
• Withdrawal: Restlessness, dilated pupils, muscle twitching, abdominal pain, fever, nausea, and diarrhea. Consider measuring opioid withdrawal using the Clinical Opiate Withdrawal Scale (COWS) (PDF - 606 KB) or the Subjective Opiate Withdrawal Scale, or SOWS for home administration.
• History of OUD-Related Events: Emergency department visits, hospitalizations, or non-fatal overdose.

Determine which patients meet criteria for a diagnosis of OUD, based on the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). The following brief criteria or a worksheet such as the DSM-5 Criteria for Diagnosis of Opioid Use Disorder (PDF - 101 KB) may help.

• Taking more, or for longer than intended;
• Inability to reduce use;
• Spending a lot of time procuring, using, or recovering from the effects;
• Craving;
• Failing obligations;
• Social problems due to use;
• Choosing over recreation or work;
• Using in physically hazardous situations;
• Using despite related physical or psychological problems;
• Tolerance;* and
• Withdrawal.*

* Note that tolerance and withdrawal do not count toward the diagnosis for people who only take opioids as prescribed, under direct medical care.²

Severity indicators for OUD are as follows:

• Two to three criteria have a mild OUD;
• Four to five criteria have a moderate OUD; and
• Six or more criteria have a severe OUD.

A comprehensive assessment of a patient's needs, including what is important to them that they hope to get from OUD treatment, will help you plan and tailor treatment for each patient. Do not delay buprenorphine simply to complete assessments. Be aware of requirements of payers you are working with, such as the need to demonstrate medical necessity for prior authorization. When assessment is completed will depend on your practice and the patient's situation. It may be completed at intake, once the patient has been stabilized on medication, or over time.

At a minimum, the assessment should include:

• Ability to participate in treatment: Potential barriers to treatment continuation (e.g., scheduling of appointments, transportation, and childcare); OUD triggers and life stressors; and personal support systems.
• Considerations for decision-making: Goals for life and treatment; patient concerns and preferences about medications for OUD; and any prior use of medications for OUD and their reason for discontinuation.
• Basic medical information: List of current medications and associated allergies; current opioid use and co-occurring substance use; and medical, mental health, and substance use histories.

As with many patients living with a chronic condition, individuals with OUD often have complex needs. Even if your practice cannot address all the patient's treatment needs, screening can help you understand the patient's needs more fully so you can connect them with appropriate care or even refer them to a higher level of care.

Screening for mental health needs, such as anxiety and depression, is recommended by the U.S. Preventive Services Taskforce,⁵ and may be more informative than simply asking the patient. Common co-occurring disorders with SUD and screening tools are as follows:

• Depression:
  • Data Element: Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] (2001) — 9-item questionnaire with a suicide risk screening item;
  • Form: Patient Health Questionnaire 2 item (PHQ-2) (2015) — 2-item short-form of the PHQ-9 without a suicide risk screening item;
• Anxiety: Generalized Anxiety Disorder 2-item (GAD-2) - Mental Health Screening - National HIV Curriculum; and
• Post-Traumatic Stress Disorder (PTSD): Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) - PTSD: National Center for PTSD (2015).

For patients who screen positive for mental health symptoms, consider referring them for Counseling and Other Psychosocial Supports and, if indicated, prescribing psychiatric medications.

Health-related social needs (HRSNs), including employment, housing, food, safety, and transportation are essential to health and wellbeing. Patients with unmet HRSNs will have more difficulty engaging with treatment until those needs are met. Consider using a screener⁶ for HRSN such as A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool: Promising Practices and Key Insights (PDF - 796 KB) or the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE).

Anything you can do to identify patients with unmet HRSN and help them address these needs will improve the likelihood of successful treatment for OUD or any other chronic condition.⁷ The North Star approach would be to identify patients with unmet HRSN and link them with appropriate community resources by doing a warm handoff to the organization and/or to have a closed loop referral, so you know the connection was made when tracking the results.

On the other hand, addressing a patient's HRSNs directly is probably beyond the scope of primary care, and just providing the patient with a printed referral list is probably insufficient to address their HRSN. Depending on the scope of your practice, patients with unmet HRSNs may be too complex to serve in primary care and may need a higher level of care to treat their OUD.

Consider screening for other needs common among people with OUD such as:

• Suicidality;
• Infectious Diseases;⁵ and
• Chronic Pain.

Depending on the patient and your practice, you may wish to assess these or refer patients for additional or a higher level of care.