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.