What is the approach to taking a sample history in a young to middle-aged adult patient with opioid dependence and possible co-occurring mental health conditions such as depression or anxiety?

Approach to Taking a History in Opioid Dependence

When evaluating a young to middle-aged adult with opioid dependence, conduct a structured risk assessment focusing on substance use history, psychiatric comorbidity, and specific risk factors that predict treatment outcomes and guide management intensity.

Essential History Components

Current Opioid Use Pattern

• Specific opioids used: Document which prescription opioids (hydrocodone/Vicodin, oxycodone/OxyContin, oxycodone-acetaminophen/Percocet) or heroin, as all activate mu-opioid receptors and fall under the same diagnostic umbrella of Opioid Use Disorder 1
• Route of administration: Specifically ask about snorting, crushing, injecting, or smoking opioids—these represent major aberrant behaviors posing imminent overdose risk 2
• Frequency and quantity: Document daily use patterns and escalation over time 2
• Source: Prescription versus illicit, multiple prescribers, multiple pharmacies (≥3 pharmacies is a red flag) 2
• Early refill patterns: This predicts prescription opioid abuse risk 2

Diagnostic Criteria Assessment

Ask directly about DSM-5 criteria for Opioid Use Disorder 1:

• Craving: Pronounced desire for opioids
• Obsessive preoccupation: Excessive time thinking about obtaining opioids
• Loss of control: Inability to refrain from use despite attempts to cut down
• Escalation: Taking larger amounts or more frequently than prescribed
• Continued use despite harm: Social problems, failure to fulfill work/school/home obligations
• Functional impairment: Specific examples of how opioid use has affected daily life

Psychiatric Comorbidity Screening

Depression and anxiety occur in approximately 40-47% of patients with opioid dependence 3, 4:

• Depression symptoms: Use validated tools like DASS-21 or ask about depressed mood, anhedonia, sleep disturbance, appetite changes, suicidal ideation 5
• Anxiety symptoms: Generalized anxiety, panic attacks, social anxiety 4
• Severity assessment: Individuals with comorbid mood/anxiety disorders demonstrate significantly more severe psychiatric symptoms and functional impairment 4
• Temporal relationship: Determine if depression/anxiety preceded opioid use or developed during use, as this affects treatment approach 6

Critical Risk Factors for Opioid Misuse

The following factors significantly predict opioid misuse and should be systematically assessed 2:

High-priority risk factors:

• Age: Younger age (18-24 years) carries higher risk; document current age 2
• Personal substance use history: Prior or current alcohol, tobacco, cocaine, amphetamine, or other drug use disorders 2
• Family history: Substance use disorders in first-degree relatives 2
• Childhood trauma: Specifically ask about sexual abuse, physical abuse, neglect 2
• Psychiatric history: Depression (OR 1.29), PTSD, psychotropic medication use (OR 1.73) 2
• Legal history: Incarceration history 2
• Motor vehicle collisions: May indicate driving under influence 2
• Current tobacco use: Cigarette smoking is a significant predictor 2

Concurrent Substance Use

• Alcohol: Use single-question screener: "How many times in the past year have you had more than 5 (4 for women) standard drinks in 1 day?" (≥1 is positive screen with 81.8% sensitivity) 2
• Illicit drugs: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (≥1 is positive screen with 100% sensitivity) 2
• Benzodiazepines: Critical to identify as concurrent CNS depressants dramatically increase overdose risk and require more frequent monitoring 7

Pain Assessment (if applicable)

• Pain intensity, location, duration: Document chronic pain characteristics 2
• Pain interference: How pain affects daily functioning 2
• Pain catastrophizing: Excessive negative thoughts about pain 2
• Previous pain treatments: What has been tried and effectiveness 2

Social and Functional History

• Living situation: Housing stability, homelessness increases risk 2
• Employment/education status: Current functioning level 1
• Social support: Family involvement, relationships affected by use 1
• Legal consequences: Arrests, probation related to drug use 2

Validated Screening Tools to Administer

For substance use risk stratification 2:

• ASSIST (Alcohol, Smoking and Substance Involvement Screening Test)
• AUDIT (Alcohol Use Disorders Identification Test) for alcohol specifically
• DAST (Drug Abuse Screening Test) or CAGE-AID for drug use
• Opioid Risk Tool (ORT): Brief questionnaire assigning sex-specific scores based on five risk factors (personal substance abuse history, family history, age, mental illness, childhood sexual abuse) 2
• SOAPP-R (Screener and Opioid Assessment for Patients in Pain-Revised): 24-item tool predicting aberrant opioid use 2

For current opioid misuse 2:

• Current Opioid Misuse Measure: 17-question self-assessment for ongoing misuse

For mental health 2:

• Validated screening tools for depression and anxiety (specific tools mentioned include DASS-21) 5

Communication Approach

Critical pitfall to avoid: Disclosures of substance use and pain must be met with compassion, empathy, and curiosity rather than judgment or labeling patients as "difficult" or "attention-seeking," as stigma interferes with self-report, treatment engagement, and recovery 2

• Discuss results openly and nonjudgmentally as a safety issue when developing treatment plans 2
• Frame assessment as universal precautions: Explain that all patients are assessed for risk factors to protect them from harm and ensure safe treatment 2
• Normalize the process: Conduct screening routinely as clinic-wide practice to reduce stigma 2

Risk Stratification and Treatment Planning

Based on assessment, stratify patients as low, medium, or high risk 2:

• Low risk: Can be treated in primary care without consultation
• Medium risk: Consider co-management with addiction specialist
• High risk: Refer to providers with extensive experience in addiction medicine 2

Important caveat: Risk stratification is not meant to deny treatment to high-risk patients but rather to determine appropriate level of care and monitoring intensity 2

Monitoring Frequency Based on Risk

• Standard patients: Reassess at least every 3 months 2
• Higher risk patients (depression, other mental health conditions, history of substance use disorder, history of overdose, taking other CNS depressants): Reassess more frequently than every 3 months 2, 7

Documentation Requirements

Document in medical record:

• All risk factors identified
• Screening tool scores
• Specific aberrant behaviors if present
• Treatment plan including monitoring frequency
• Referrals made to specialists if indicated