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Assessing opioid addiction
Carefully assess patients by following these steps:
- Take a history of alcohol and other drug use.
- Take a psychiatric history:
- Addiction to opioids can cause depression and anxiety through a direct organic effect. This is common in patients who are taking high doses of sedating drugs such as opioids, alcohol or benzodiazepines.
- Addiction to opioids can also cause depression by disrupting social relationships, finances and other aspects of the person's life. It is not uncommon for a patient who is addicted to opioids to say, "If I don't get treatment, I will kill myself."
- Ask about functioning (e.g., family, work) before and after starting opioids.
- Ask about problems related to opioid use (e.g., conflicts, poor function at work).
- Determine the pattern of use (binge versus scheduled).
- Determine the analgesic effectiveness of the current dose.
- Investigate the psychoactive effects of the current dose. Patients who show signs of addiction find that opioids relieve anxiety and induce a sense of calm, peace and energy.
- Ask about withdrawal symptoms:
- How long has the patient been able to go without opioids?
- Was the patient uncomfortable during this period?
- Has the patient ever used opioids to avoid withdrawal or relieve withdrawal symptoms?
- Determine whether the patient is experiencing withdrawal-mediated pain. Consider withdrawal-mediated pain in patients who report:
- intense magnification of their pain as the opioid wears off
- diffuse myalgias ("pain all over")
- severe pain and withdrawal symptoms in the morning, with quick relief after taking the opioid.
- Be alert for drug-related aberrant behaviours (e.g., double doctoring or obtaining opioids from family or friends, or on the street).
- Complete a physical examination.
- If possible, interview the patient's spouse or another close family member because they may be the first to notice opioid-related problems:
- Do not interview the spouse if you have concerns about spousal abuse.
- Patient confidentiality must be preserved, so conduct the interview with the patient present (implied consent), or collect written patient consent.
Collecting additional information
Gather information about the following issues and use other sources of information to complete the assessment:
- Injection opioid use: Check for needle marks in the antecubital fossa, hands, feet, groin and neck.
- Opioid intoxication: Check for pinpoint pupils, nodding off, drowsiness, sweating.
- Opioid withdrawal: Check for restlessness, piloerection (goosebumps), sweating, increased bowel sounds, lacrimation, sniffles, dilated pupils, muscle tenderness, tachycardia and hypertension.
- Liver disease: Check for jaundice, hepatosplenomegaly, stigmata of chronic liver disease, ascites.
- Laboratory tests:
- Elevated ALT and positive hepatitis C antibodies suggest past or present injection drug use.
- Elevated GGT and MCV often indicate heavy alcohol use.
- Urine drug screening can reveal diversion, non-compliance or another substance use problem.
- Past records: A phone conversation with the patient's previous family physician, with patient consent, may reveal clinically important information.