Screening for Initiation of Medication Treatment for OUD
Screening
- OUD screening is essential and does not require clinical expertise. Individuals with OUD are at risk for significant harm, and thus all such persons should be screened for OUD and provided referral for initiation and maintenance of medication if positive, even before placement in treatment court if necessary.
-
The completion of an assessment or
placement in treatment court should not
delay medication for OUD treatment.
- The 2020 ASAM guideline for the treatment of OUD states: "Comprehensive assessment of the patient is critical for treatment planning. However, completion of all assessments should not delay or preclude initiating pharmacotherapy for opioid use disorder. If not completed before initiating treatment, assessments should be completed soon thereafter."
- Counseling and other behavioral interventions can be more effective after medication for OUD and medical treatment are initiated.
- It is critical to alleviate any withdrawal symptoms and cravings first, then initiate psychosocial interventions after stabilizing the treatment court participant.
- There may be times when psychosocial interventions begin before medication for OUD in the treatment court; however, psychosocial intervention should not replace medication for OUD.
- Treatment courts and settings where individuals are screened for treatment court eligibility should be able to immediately connect to qualified healthcare providers who can quickly initiate medication for OUD for individuals at risk for opioid withdrawal and to prevent recurrence and overdose.
- An opioid-positive urine drug screen is not necessary to initiate medication for OUD. A quick and validated OUD screening tool used in justice settings by both clinicians and nonclinicians is the Rapid Opioid Dependency Screen (RODS).
- Following a positive RODS screen, the person can immediately be referred for final OUD diagnosis, assessment, and treatment by a doctor or other healthcare professional who can prescribe medication for OUD.
Diagnosis
- A doctor will verify a diagnosis of OUD before prescribing medication for OUD.
- Diagnosis and/or referral for evaluation are also conducted for any suspected mental health or medical disorders.
- All persons with signs or symptoms of medical discomfort that could indicate opioid withdrawal or any other medical problems, including diarrhea, vomiting, pain, etc., should be immediately referred for evaluation that could also include immediate treatment of opioid withdrawal. (See Table 4 for a list of withdrawal symptoms.)
| TABLE 2. RAPID OPIOID DEPENDENCE SCREEN (RODS) | ||
|---|---|---|
| 1. Have you ever taken any of the following drugs: | Yes | No |
| Buprenorphine | ||
| Methadone | ||
| Buprenorphine | ||
| Morphine | ||
| MS Contin | ||
| Oxycontin | ||
| Oxycodone | ||
| Other opioid analgesics (e.g., Vicodin, Darvocet, Fentanyl, etc.) | ||
| If no to all of the above, skip to the scoring instructions. | ||
| 2. Did you ever need to use more opioids to get the same high as when you first started using opioids? | ||
| 3. Did the idea of missing a fix (or dose) ever make you anxious or worried? | ||
| 4. In the morning, did you ever use opioids to keep from feeing "dope sick" or did you ever feel "dope sick"? | ||
| 5. Did you ever worry about your use of opioids? | ||
| 6. Did you ever find it difficult to stop or not use opioids? | ||
| 7. Did you ever need to spend a lot of time/energy on finding opioids or recover from feeling high? | ||
| 8. Did you ever miss important things like doctor's appointments, family/friend activities, or other things because of opioids? | ||
| Scoring instructions: Add the number of "yes" responses for Questions 2 to 8. If the total answer is ≥3, the RODS screen is positive. | ||
Adapted from Wickersham, J. A., Azar, M. M., Cannon, C. M., Altice, F. L., & Springer, S. A. Validation of a brief measure of opioid dependence: The Rapid Opioid Dependence Screen (RODS). Journal of Correctional Health Care, 21(1):12-26.
Drug Testing
- Drug testing during assessment and treatment should be conducted in alignment with the All Rise Adult Treatment Court Best Practice Standards 2nd Ed. and national clinical standards as found in The ASAM National Practice Guideline for the Treatment of OUD, 2020 Focused Update.
- Drug testing can be used in conjunction with participant self-report and should never be relied upon as the sole means for assessing substance use. Definitive testing should always be used when the results will help with clinical or treatment court decision-making.
- Positive testing alone should rarely result in detention or other stringent sanctions for participants with moderate to severe OUD who are otherwise substantially complying with court and treatment requirements (e.g., attending treatment sessions and court hearings and reporting for drug testing).
- Clinicians are perfectly positioned to advocate for participants who may have experienced a recurrence discovered by testing or self-report. This is an opportunity to openly communicate about engagement in treatment and triggers in the individual's life and environment. An effective response to recurrence does not require punishment or reduction of privileges, but instead requires reassessment of the treatment plan. This may include incorporation of motivation enhancement approaches, functional analysis of the recurrence, or other therapeutic adjustments, including changes to the dose or types of medications for OUD treatment.
- ASAM has published guidelines outlining best practices for drug testing in addiction settings entitled The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine.
Connecting Participants to an Appropriate Medication for OUD
- All persons in the court or other settings can assist the participant in gaining access to medications for OUD: judges, law enforcement officers, probation officers, counselors, etc.
- The courts should not determine which medications are available to a participant, nor should they attempt to help participants make decisions regarding medications for OUD. These are medical decisions.
- Counselors collaborate in shared decision making between the prescribing clinician and participant to choose from appropriate and available treatment options. Potential benefits and risks for each available option should be discussed.
- Prescribing clinicians consider the participant's current symptoms and co-occurring illnesses as well as their preferences, past treatment history, and setting when deciding between the use of methadone, buprenorphine, and extended-release naltrexone for OUD.
- Local and state agencies for addiction treatment usually maintain lists of credentialed providers, including those authorized to provide office-based treatment with buprenorphine.
- Contact state or county boards of health to identify medical practitioners offering addiction treatment in the local area.
- Linkage should include engaging the participant in understanding and consenting to medication and ensuring continuity of care through the use of coordinators, case and care managers, recovery coaches, peer mentors, etc.
- Peer support workers have been found to be helpful in the process to coordinate and bring criminal justice—involved persons to their appointments. Using such workers lowers the barrier to treatment.
