Screening and Diagnosis

Screening for opioid misuse and opioid use disorders can help identify potentially harmful drug interactions, inform clinical decisionmaking and prescribing practices, and help patients in need get access to treatment.

Practices should decide which standardized screening tools they will use and design a protocol to incorporate screening into the patient workflow. A number of these instruments may be self-administered online or on paper. For those that require providers to administer the screening instruments, it may be more efficient to have nonphysician providers such as nurses or clinical assistants do so.

Treatment Improvement Protocol 63: Medications for Opioid Use Disorder (PDF—700 KB) recommends universal screening of patients for opioid misuse given the high prevalence of substance use disorders presenting in primary care.

The National Institute on Drug Abuse provides a chart comparing evidence-based screening tools and assessments. Possible screening tools include:

• Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS).
• Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (PDF—333 KB).
• NIDA-Modified ASSIST: Quick Screen (NM ASSIST).
• Opioid Risk Tool (PDF—192 KB).
• CAGE-AID (PDF—73 KB).
• Drug Abuse Screening Test (DAST-10).

Many of these brief instruments also screen for other substances with abuse potential. Patients who report misuse of substances should be asked further about the extent of their use and assessed for a substance use disorder.

Some practices or organizations may adopt a Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. While the effectiveness of this model has only been proven to help those with risky alcohol use thus far, it offers an approach to systematically integrate screening and intervention in primary care settings across substances. This model aims to identify individuals at risk for substance use disorders and intervene early before there is a need for more extensive or specialized treatment. It consists of three components:

1. Screening—assess patients for risky substance use behaviors with standardized screening tools.
2. Brief Intervention—engage patients in a short conversation about their risky behavior.
3. Referral to Treatment—provide a referral to therapy or additional treatment.

Providers should check whether their patients are receiving prescriptions for controlled substances from other healthcare providers. A prescription drug monitoring program (PDMP) is an electronic database that collects and monitors prescribing and dispensing data. These data are submitted by prescribing providers and pharmacies.

PDMPs can help identify patients who may be misusing or diverting prescription opioids. Practices should ensure their providers’ full participation in PDMPs when prescribing opioids. Characteristics of PDMPs may vary across States, including the type of agency responsible for the PDMP, drug schedules monitored, and people to request information from the database. Visit your State’s PDMP website for more information.

Conduct a followup assessment for opioid or other substance use disorders when patients:

1. Screen positive on a brief assessment related to opioid or other substance misuse,
2. Disclose opioid or other substance misuse, or
3. Have signs or symptoms of opioid or other substance misuse.

The program should decide which members of the care team will conduct which components of the assessment. At a minimum, it should include:

• A complete health history (i.e., medical, mental health, and substance use);
• A physical examination for signs and symptoms of opioid use;
• Diagnosis of opioid use disorder;
• Other relevant medical conditions (i.e., pregnancy testing, liver function, hepatitis B and C testing, HIV testing); and
• Other relevant psychiatric disorders, including depression and specifically, suicidal ideation (i.e., Patient Health Questionnaire [PHQ-9]).

The physical examination should look for the signs of current opioid use, withdrawal, or related medical consequences. Signs of opioid intoxication include drowsiness, constricted pupils, slurred speech, impaired memory, and changes in mood. Symptoms of withdrawal may include restlessness, dilated pupils, muscle twitching, abdominal pain, fever, nausea, and diarrhea. The Clinical Opiate Withdrawal Scale (COWS) (PDF—610 KB) is an instrument to assess common signs and symptoms of withdrawal from opioids.

Next is a diagnostic assessment for opioid use disorder. This assessment should be conducted in an empathetic, nonjudgmental manner that uses thought-provoking and open-ended questions. Use a worksheet to assess the DSM-5 Criteria for Diagnosis of Opioid Use Disorder (PDF—100 KB).

Patients who meet:

• Two to three of the above criteria have a mild opioid use disorder;
• Four to five criteria have a moderate opioid use disorder; and
• Six or more criteria have a severe opioid use disorder¹

Based on the severity of the patient’s opioid use disorder and individual needs, providers should determine whether they can provide care within their practice or should refer the patient to another treatment setting for substance use treatment services or specific components of care. As practices begin to design and implement their MAT program and hold initial discussions regarding their scope of practice, the team should decide on the criteria that make a patient a good candidate for MAT in their care setting. These criteria may depend on the providers’ comfort levels and resources available. For example, the Vermont Treatment Needs Questionnaire (PDF—140 KB) helps community-based clinics assess at initial contact if patients are appropriate for office-based opioid treatment.

The American Society of Addiction Medicine (ASAM) categorizes treatment settings into levels that reflect a continuum of care, some of which reflect the outpatient services most typical of users of this Playbook. The ASAM Criteria can help guide providers to determine the appropriate level of care by assessing six dimensions to identify the patient's needs, barriers to treatment, and resources available.

While the ASAM Criteria can be useful in specialty substance use treatment settings, it may be less applicable or practical to use in primary and other ambulatory care settings. ASAM offers another brief level of care screening tool, ASAM CONTINUUM^® Triage (CO-Triage^®). This tool helps providers make provisional level of care recommendations. In busy primary care practices, providers may find this shorter version easier to integrate into workflows.

The results of this assessment and treatment options should be discussed with the patient. If the patient is not interested in treatment at this time, providers should use motivational interviewing strategies to further probe their resistance.¹ If the patient has needs beyond the capacity of your organization or practice, refer to a higher level of care.