What is the recommended screening process for patients being considered for Medication-Assisted Treatment (MAT) for opioid use disorder?

Recommended Screening Process for Medication-Assisted Treatment (MAT) for Opioid Use Disorder

Universal screening with validated tools should be implemented for all patients being considered for Medication-Assisted Treatment (MAT) for opioid use disorder, followed by a comprehensive assessment of substance use history, mental health status, and risk factors for opioid misuse. 1

Screening Tools and Approach

Step 1: Initial Screening

• Implement universal screening regardless of provider suspicions to avoid bias and missed diagnoses 1
• Use validated screening tools:
  • ASSIST (Alcohol, Smoking and Substance Involvement Screening Test)
  • DAST (Drug Abuse Screening Test)
  • CAGE-AID for drug use
  • Single-question screener: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (Positive if ≥1) 1

Step 2: Risk Assessment

For patients who screen positive, conduct risk assessment using:

• Screener and Opioid Assessment for Patients with Pain (SOAPP or SOAPP-R)
• Opioid Risk Tool (ORT)
• DIRE (Diagnosis, Intractability, Risk, Efficacy) instrument 1

Step 3: Comprehensive Assessment

Assess for:

• DSM-5 criteria for opioid use disorder 1
• Prior history of substance use disorders (including alcohol and tobacco)
• Family history of substance use disorders
• Childhood trauma
• Personal/family psychiatric history
• History of motor vehicle collisions (possible marker for driving under influence) 1

Mental Health Screening

Mental health screening is essential as part of the MAT evaluation process:

• Screen all patients for depression using the two-question screener:
  1. "During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless?"
  2. "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?"
• If positive, follow up with: "Is this something with which you would like help?"
• Use the Patient Health Questionnaire-9 (PHQ-9) for more comprehensive depression assessment (refer for psychiatric evaluation if score ≥10) 1
• Screen for neurocognitive disorders that may affect treatment adherence 1

Physical Assessment

• Conduct opioid-free status verification before starting antagonist therapy
• For patients transitioning to naltrexone:
  • Ensure patients are opioid-free for 7-10 days (for short-acting opioids)
  • Patients transitioning from buprenorphine or methadone may need up to 2 weeks opioid-free 2
• Consider naloxone challenge test to verify opioid-free status before naltrexone initiation 2

Special Populations Considerations

Adolescents and Young Adults

• For adolescents over 16 years, medication for opioid use disorder (MOUD) is the front-line treatment
• Should be augmented with developmentally appropriate behavioral interventions 1
• Recommended best practice: minimum 52 weeks of buprenorphine with psychosocial interventions 1

Pregnant Women

• Universal screening recommended at first prenatal visit
• Screening should be easily administered, acceptable to patients, and economical
• Biologic testing (urine, blood, hair) should not be used for universal screening but may be appropriate in specific situations with patient consent 1

Common Pitfalls and Caveats

1. Underidentification: Only 8.5% of adolescents who need substance use treatment actually receive it 1. Universal screening helps identify more patients needing treatment.

2. Risk of precipitated withdrawal: Failure to ensure adequate opioid-free period before starting naltrexone can result in severe withdrawal requiring hospitalization 2.

3. Stigma and bias: Provider suspicions alone are subject to conscious and unconscious biases that may overburden some groups and leave others undiagnosed 1.

4. Inadequate mental health assessment: Depression, suicide attempts, and suicidal ideation have been reported in patients taking naltrexone. Monitoring for these symptoms is essential 2.

5. Discontinuing screening after initial assessment: Patients should be continuously monitored throughout treatment, especially during specialty care and emergency visits 1.

By implementing this comprehensive screening process, clinicians can better identify patients with opioid use disorder, assess their specific needs and risks, and develop appropriate treatment plans that improve mortality and morbidity outcomes through evidence-based medication-assisted treatment.