Answering Questions

Ukranian art by Anna Shevel

“Addiction is considered a behavioral mental health disorder, correct?? So what types of diagnostic testing are useful when determining the level of care for someone who’s seeking treatment for an opiate use disorder? Or is the notion of attempting scientific evidence to verify or properly assess patients like these just not practical? surely there’s even one test that a physician should perform besides a standard urine screening (??) Urine test can only verify the presence of an opiate, on one particular day, one occasion, right? In theory I could visit the dentist, take a prescription pain killer one time and then be equally qualified for any MAT program that’s relying on only a urine test! Or maybe I’m just confused… Thank you”

I decided to answer my reader’s question in the form of a whole blog, given the complexities of what the poster is asking.

This is really a two-part question; the first part involves how doctors diagnose opioid use disorder, and the second is how they decide the appropriate level of care.

Let’s take the first question. We use the DSM 5 criteria to confirm a diagnosis of opioid use disorder, and the criteria also help describe the opioid use disorder as mild, moderate, or severe:

My reader is correct: one positive urine drug screen for opioids isn’t diagnostic for opioid use disorder. We need patient histories to confirm the diagnosis. As you can see, all but one (physical withdrawal) of the eleven items are based on patient history, which is why providers who use medications to treat opioid use disorder usually ask new patients to come to arrive in withdrawal. But even when that’s not possible, there are workarounds.

Upon meeting a new patient, I ask her to tell me her story: how she started use, how the use changed over time, what happened in her life. I settle into my chair and listen carefully, trying my best not to interrupt.

I’m listening for common themes, keeping in mind the diagnostic criteria. I’ve talked to thousands of patients over the past twenty-one years, and the histories are similar but not identical. If the patient has an unusual history, I’ll ask questions for clarifications. Some patients are vague with poor memories and other patients recite a straightforward history that I could type word for word. Most are somewhere in between.

Though patient history is a big part of making the diagnosis of opioid use disorder, it’s only one piece of the diagnostic pie, though it is a large piece. We have other factors.

For example, we do point of care (immediate results) drug screens on admission. These results should match the patient’s history and show the opioids the patient has used most recently. If that screen is negative for opioids, we need to know why. Perhaps our test is limited, or it’s been too many days since last use. If the drug screen doesn’t match the history, we need to take a closer look.

We look at prior treatment or lack of it. If I already know the patient from a previous admission, the diagnosis has already been made. We only need to make sure the patient is still appropriate for treatment at our level of care.

I’ll ask for old records. If the patient has had prior treatment elsewhere, I want to see those records, for information not only about diagnosis, but also how the patient did in treatment. It’s nice to get that information before starting treatment but that’s not always possible. Usually, we can get this data within the first 24-48 hours.

I check our state’s prescription monitoring program to look for prior opioid prescriptions and prior buprenorphine product prescriptions. Again, findings should match patient history. If the patient gives a long history of opioid prescriptions from pain clinics, I should be able to see them on our PMP. If I can’t, I need to ask which state the patient filled them in, and when. I might need to double check the patient’s birthdate or spelling of name. Now with so many people using heroin/fentanyl, most patients have limited data on the PMP, which is a big change from five years ago.

I do a physical exam. We ask patients to come for intake in at lease mild withdrawal if possible, so that I can see signs of opioid withdrawal. I look at the size of the pupils, watering of eyes and nose, goosebumps, tremor, and at the blood pressure and heart rate. I look for needle marks on the skin if the patient gave a history of intravenous use. I look for muscle jerks and overall appearance.

While it’s true that other things can cause physical signs that mimic some opioid withdrawal signs (benzodiazepine withdrawal, stimulant intoxication), it’s another way to confirm the patient’s history.

Occasionally I ask for collaterals, with patient permission. Collaterals are family or friends who can confirm the patient history. They aren’t available for every patient but can be helpful. At our opioid treatment program, we often have patients come for admission because they have relatives in treatment with us, and collateral information is easily obtained. Sometimes family will come with the patient and can be a source of information if the patient permits.

But what my reader was really asking was this: What keeps a patient from lying to the physician to meet criteria to start methadone or buprenorphine?

Of course patients can lie. But why would they? Unless they have opioid use disorder, starting medications like methadone and buprenorphine would cause a new problem for them – physical dependency on opioids. If they lied, saying they already had this problem, they would create a new problem for themselves.

And at the end of my evaluation, when I’m reviewing the consent form for treatment, I make sure the patient understands that if they start buprenorphine or methadone, they will be physically dependent on the medication.

I tell patients that the medication – mostly methadone – can cause some euphoria in some patients, but it wears off. Anyone starting treatment with methadone only to feel euphoria is making a huge mistake that they will regret.

The most common reason the patients that I see don’t qualify for admission to the opioid treatment program is that they aren’t using opioids. About once a month or so, a patient who wants to stop using methamphetamine will come for admission. For some reason, they believe buprenorphine or methadone will help them stop using methamphetamines. I tell them I’m glad they came for treatment, and we can help them access the right kind of treatment. But starting methadone or buprenorphine isn’t the right thing to do, since they aren’t already using opioids. In fact, there are no evidence-based FDA approved medications to help with methamphetamine use disorders. We’ve had plenty of medications show initial promise, like naltrexone, bupropion, mirtazapine, and others, but none (as of today) have enough evidence to use with confidence they will help.

Once we determine our patient has the diagnosis of opioid use disorder, we need to select the appropriate level of care. This is easier. We use the American Society of Addiction Medicine Criteria:

  • Acute Intoxication and/or Withdrawal Potential.
  • Biomedical Conditions and Complications.
  • Emotional, Behavioral or Cognitive Conditions and Complications.
  • Readiness to Change.
  • Relapse, Continued Use or Continued Problem Potential.
  • Recovery and Living Environment.

In most cases, if the patient has no urgent medical or mental health issues, outpatient treatment with methadone or buprenorphine (or rarely, naltrexone) and counseling will be the appropriate level of care.

There are some exceptions. Federal regulations say patients can’t start on methadone without at least one year of physical dependence.  And if the patient has only mild opioid use disorder using the DSM criteria, patients might be better served with non-medication treatment, though that’s debated by experts.

It’s rare for me to see a patient with less than a year of opioid use and I rarely see a patient with mild opioid use disorder. I can still admit them to the opioid treatment program if I submit a request for an exception to the rules to our state’s SOTA and the federal government too, and the few times I’ve needed to do this, it was quickly approved by both agencies.

I hope this answers my reader’s questions. We do have diagnostic criteria, and we do have placement criteria that we follow for best results.

20 responses to this post.

  1. Posted by Trudy Duffy on June 6, 2022 at 12:33 pm

    A thoughtful, detailed and helpful post. Families trying to help someone would benefit from reading this.


  2. Posted by Charles Erickson on June 6, 2022 at 12:44 pm

    Yes. A very comprehensive entry. I am glad that the substance use disorder patients in your vicinity have your services. It really helps that you yourself are in recovery. I have found that nobody can really understand the disease unless they have experienced it themselves. Thank you.


    • Thank you…but some of the best practitioners I’ve met haven’t had the disease themselves.


      • That’s the one thing medical school can’t give a specialist. And oddly enough I truly believe that anyone who has experienced it themselves should be deemed automatically an expert! Because I can write all day and night about what pure hell it is. But until I FEEL it in my body and my soul, it’s simply something I’ve studied and may know a lot about.

  3. Posted by Alan Wartenberg MD on June 6, 2022 at 4:54 pm

    Jana is an excellent practitioner of Addiction Medicine, but I would point out that the membership of the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry together have thousands and thousands of members who are dedicated to give empathetic and quality care to their patients. The ASAM and AAAP websites can direct people to certified addiction specialists in their area.


  4. Thank you sincerely from the bottom of what’s left of my heart! I wasn’t sure if you understood what I needed to know. Plus I wanted to also make suggestions. If it’s not disrespectful that is?
    If it is disrespectful,,then well. I apologize in advance! I’m not doctor of course. Not even on TV. Hope it’s alright if I ask…

    But isn’t this kinda like offering liquor regularly to a person who’s struggling with alcohol? Ok so after they approach their doctor to address concerns about their weekend binge drinking,, Granted this type of behavior is usually only the beginning of the end, right??
    Eventually their drinking will escalate and at some point they will develop the physical symptoms of withdraw when they try to stop. So offering to deliver a keg of beer each morning before work in an effort to help manage their weekend binges, probably will only escalate their condition??
    And it’s not as if they were lying entirely when they admitted to their doctor that they’d been regularly abusing alcohol and noticed it might be a problem. Especially come Monday.
    This area gets tricky for me!(big surprise) But I’ll be candid and admit I’m not even sure if it’s at all possible to lie to a Dr to begin with. I mean aren’t they supposed to know what’s wrong, scientifically, medically prior to administrating treatment? Or are they only “basically” sure that they know what’s wrong with a patient before they begin whipping out prescription pads & making recommendations? Let’s be reasonable if I tell my Dr I have cancer and I think he needs to begin chemotherapy ASAP, well shouldn’t be verify this information first??
    And obviously no one is perfect! Doctors are fallible human beings just like everyone else is(except me, exception to Ruhl Lol) I guess I wanted reassurance that before I just hand over my body and my trust, that there’s some damn good safe guards in place so I don’t have to suffer. Not everyone with an opiate use disorder is by virtue automatically physically dependent on opioids to the extent that methadone maintenance will help,,,?? Or is that wrong?? And patients have only themselves to blame when their health concerns can’t be properly addressed because they weren’t totally honest upfront. However, as a general matter I ALWAYS assumed that no matter what I was prescribed or what was medically wrong with me that it was impossible to get hurt at a Dr appointment. Probably presumptive of me but I assumed that anyone who attempted to lie or was even mistaken about their condition. The qualified expert would catch it. And make appropriate suggestions on how to fix it.
    Since behavioral mental health disorders are probably going to affect many aspects of a person’s life I thought maybe one way to check and make sure someone actually warrants this level of treatment was by performing a criminal background check. Also family court hearings, complaints within the child welfare system. Hell a credit check might hint that someone can no longer have their own checking account due to a drug problem. Could be significant..? Or maybe not. Maybe they’re dirt ass poor and they’ve been unlucky. That’s when it’s necessary to sit down and consider EVERYTHING. Timelines might be far more effective than providers realize. Totality of evidence. In my own case it certainly was. Unfortunately if someone in your office is looking to lie and score, they’re only harming themselves. It’s not meant to be sampled. Even if they’re simply naive. You’re the only person who can protect them. Honestly. If I was signing informed patient consent in your office and you mentioned I’d become opioid dependant on methadone. I might nod that I understand what you’re saying. Truthfully I had never heard that term before. And if you had decided to explain that withdraw hurts. I was such a coward I would have thanked you for you time. Then I’d probably walk out of your office and hopefully I’d do better much on my own. Not treating me was how you helped me on that day.
    Thanks again. Brilliant!😘

    “All poodles are dogs, not all dogs are poodles”


    • Ps I would personally appreciate it if a doctor explained to me that there was a chance I’d be discriminated against simply because I was enrolled medicated assisted treatment. A head’s up. Backing up back up!


    • Thanks for bringing up a common misperception…so many people ask, “But aren’t you just changing one drug for another?”
      The answer is found in the unique pharmacology of methadone, and buprenorphine. Instead of a patient using short-acting opioids like heroin, fentanyl, and pain pills, we switch them to these long-acting medications that can be dosed once per day and keep people with opioid use disorder out of withdrawal. Other than having to come get their dose once daily, they can lead normal lives. They are freed from constantly looking for drugs to keep withdrawal at bay.

      We make our own opioids, called endorphins. When people use opioids over a period of time, their bodies stop making these endorphins. Then when the outside opioids are stopped, people feel bad, both because they are in withdrawal from the opioids they are accustomed to taking, and because they lack endorphins. This is a simplistic way to explain it and it is much more complicated, but that’s the general idea. The methadone or buprenorphine replaces the endorphins that the body should be making, but isn’t. And at stable doses of methadone or buprenorphine, the patient isn’t impaired and can work, play, do normal life things.

      Most diseases are diagnosed by patient history. That’s why it’s so important to listen to patients when they come to us for help. Physical exam and testing helps confirm diagnoses, but the patient history is of upmost importance.
      You ask great questions!


  5. Posted by Smoky Mountain Rain on June 10, 2022 at 12:56 am

    As to diagnosing opiate use disorder in me it’s really simple. I try to be as much help as possible. Every time I’ve entered MAT I’ve been told to come in withdrawal. I never could do that so I just came in loaded to the gills. No danger of misdiagnosis or misinterpretation of my mental and physical condition this way.
    As a provider how might you best proceed in this case?
    Each Dr. touched on the situation at hand and I was admitted that day.


    • I’m not sure you mean by loaded to the gills. I know if I see a patient who is falling asleep or obviously impaired, I can’t start them on medication that day, due to safety concerns. Also, if the patient’s impaired he can’t give informed consent for treatment.


  6. You mentioned that methadone/subuouxe replace the endorphins that a person has presumably stopped manufacturing. In regards to subuouxe specifically, is it possible to produce them again once you’ve been on medicated assisted treatment for a very long time? As far as you know is there no difference between methadone and subuxone when it comes to the withdraw involved? I realize that both are opioid medications. But I had heard methadone was a full antagonist and subuxone a half antagonist. Have you been acquainted with someone who can help explain the differences? What it feels like?
    I don’t understand why anyone would suddenly wake up one day after they had been stabilized on either drug and then taper off voluntarily(?) However if there’s anything significant about the withdraw from these two medicines, I’d like to know what. Opioids are not a problem until you no longer have them anymore. Society still frowns on using medicated assisted treatment. Expecting addicts to have superhuman powers. Thank you very much for your time


    • Great question! But we don’t know the answer. Since endorphins are located in the central nervous system, we can’t measure or monitor directly without some invasive procedure.

      Some patients are able to taper off opioids and they feel fine with no long-term withdrawal symptoms, while others feel mildly lousy for months and months. Right now we don’t know why patients are so different, but I suspect we’ll discover some day that it’s due at least partly to genetics.


      • “mildly lousy for months and months…” Implying that “lousy” doesn’t last years and years??? Today I suddenly realized that while alive on this Earth I’ve spent more than half of it obtaining my “endorphins” via artificial means..I mean my body hasn’t had to produce its own opiates in long time. Too bad there’s no refresher courses I could provide! The one thing I did take notes of while in methadone withdraw was that it was possible to get from minute to minute without sobbing as long as I was listening to music. Sounds silly but I was a singer throughout school, never auditioned for a solo that I didn’t get. And while I was terrified and hysterical without methadone, music did offer some relief. I’d lock myself in the bathroom and sing my ass off. Probably psychological but since my body couldn’t respond to anything else, medicine, drugs, music seemed to soothe me for about five seconds or so. Ratio, five straight minutes terrified and then five seconds I’d revisit planet Earth again while singing out loud!! Honestly it’s agony. I’d give anything to jump back into my former body. ANYTHING**

  7. Soo “invasive” procedures, I’d almost donate what’s left of my brain to science if necessary! People usually don’t believe me when I tell them that methadone withdraw was traumatic. I didn’t know what to expect from subuouxe withdraw. And it’s frightening. I choose my words carefully. FRIGHTENING and isolating. Anxious.
    Thank you very much


  8. Posted by RAZ1973 on June 15, 2022 at 11:46 pm

    Interesting comment above – because it kind of goes with my comment. I’ve been taking suboxone for almost 6 years. My maintenance dose is not very high, but so far my attempts to taper off the medication have not gone well at all. As much as I appreciate the MAT clinic I’m a part of, they don’t have a lot of help to offer when it comes to getting off suboxone and seem surprised that anyone would have difficulty doing so. Are there any good resources available to help people successfully get off these meds should they choose to do so? Unfortunately I’ve heard some horror stories, especially what it’s like towards the end of the taper (and I have my own memories of being put on a super high dose of suboxone in detox and then being yanked off completely in just a few days, but that’s a whole other story…). Really appreciate your blog and your willingness to engage and help folks like us!


    • Thank you, and I think there’s little data to show that one method of taper is better than another. Before my patients start a taper we talk about how prepared they are to deal with possible triggers for relapse: – health issues that may involve pain treatment with opioids, -strong negative emotion, because bad things happen in all of our lives, – and being around drugs unexpectedly. It’s essential not to taper too soon – sometimes not at all – because relapse can be fatal.
      Assuming they are ready, we go very slowly. I ask them to taper so slowly that it doesn’t interfere with their ability to function normally. Ordinarily it takes months to years, with the last 2mg being the slowest.
      Right now I have a half dozen patients on less than 1 mg per day. I prescribe the 2mg films and they cut them into small amounts. They’ve all been in treatment for more than 8 years and are extremely stable.
      From what I’ve seen it’s very important not to jump up & down on your dose, remembering that since it’s a long-acting medication, the change we make today may not be felt by the patient for 4-5 days.
      Having said that, most patients who have tapered off just go at their own pace, get down to .5mg per day or less, then quit. I’m fortunate that I have a bunch of patients who were started on buprenorphine early on, and are solid in their recovery and wish to taper. I tell them there’s nothing wrong with staying on the medication, either. I honor their wishes.


      • It’s touching that when read your posts I am validated as a human being. The most difficult part of needing an opiate every day to be normal is knowing that everyone else sees me as a failure because I need medicine just to endure normal life activities. I wish I wasn’t ashamed about that part. I wish I didn’t need anything just to wake up and hop in the shower each morning. But regardless of how or why it occurred, I’m not alright without my medicine. I do apologize to everyone for letting them down.
        During hurricane Katrina I sat glued(like most folks) to the television set. All I could imagine was the people who were struggling to obtain necessities while also opioid dependant. It’s a different world for those of us who can’t manage without medicine. Thank you

  9. Oh wow, guess I should have already asked about this placement criteria but unfortunately I’m in the midst of my own opioid crises and it slipped my mind!!
    Ok if you were about to admit someone into treatment based partially on the assessment they had answered, you’d probably want to look and see how many different times they’d been admitted into some type of treatment program, right? You’d check the database for any ongoing opiate prescriptions? And probably make note of the number of opiate prescriptions prescribed in their past? Correct? I mean if you didn’t see anything, you’d move on right? You’d examine that individual physically and note injection scars on their veins, you’d also notice the person’s posture and even their speech. I find it impossible to stand up straight! It’s also one of the very very times in my life when I’m practically speechless. I also cannot sit or stand for more than a minute or two without switching up. I usually have a sense of tunnel vision which means I shake my head and tremble all over. I’m not in the mood for conversation at that point! In fact if I was talking more than average patient you could probably bet that I’m not in withdraw. And it’s painful to have a full bladder at that point. I usually avoid drinking liquids so I won’t have to experience the agony of a full bladder! (Yeah, I was sick) But Drs are aware of these things, correct???
    The best doctor who ever treated me once interuptted me as I was in the middle of begging for help, “I can see that you’re very sick. Let’s get you some medicine and then we can talk more!” I was so grateful that I didn’t have to explain any further! He wasted no time. He didn’t just expect the registered nurse to hurry either. He personally supervised. Twenty minutes later I sincerely thanked him for his compassion. I had waited months for that one appointment. But by that point I’d had many treatment programs under my belt. These are the hallmarks.


    • And I had trouble in my past being accepted into subuxone programs as well as rehabs die to the fact I had been on methadone for many years prior to seeking help at that point. I would usually lie about being a methadone maintenance patient. It worked well as long as I lied


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