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

Recommended Approach to History-Taking in Young to Middle-Aged Adults with Opioid Dependence and Co-Occurring Mental Health Conditions

When evaluating a young to middle-aged adult with suspected opioid dependence and possible co-occurring mental health conditions, systematically assess opioid use patterns, route of administration, functional impairment, psychiatric comorbidities, and psychosocial risk factors using validated screening tools, as this population has a 64.3% prevalence of co-occurring mental illness and requires comprehensive assessment to guide treatment intensity and prevent mortality. 1, 2

Essential Opioid Use History Components

Document specific opioid use patterns with the following critical elements:

• Route of administration: Specifically ask about snorting, crushing, injecting, or smoking opioids, as these represent major aberrant behaviors posing imminent overdose risk 1
• Daily use patterns and escalation: Document frequency, quantity, and progression over time to determine severity 1
• Source of opioids: Distinguish between prescription (legitimate or diverted from family/friends) versus illicit sources (heroin, street fentanyl), as this guides management intensity 1, 3
• Functional impairment: Obtain specific examples of how opioid use has affected work, school, relationships, and daily responsibilities—this determines OUD severity 1
• Motivations for use: Ask whether the patient uses primarily for pain relief (reported by 56-60% of young adults) versus non-pain motives like getting high or relaxation, as young adults are more likely than older adults to endorse non-pain relief motives 3, 4

Critical Risk Factors to Assess

Systematically evaluate the following high-priority risk factors that increase opioid misuse risk 2-3 fold:

Substance Use History

• Personal substance use: Document current or prior alcohol, tobacco, cocaine, amphetamine, cannabis, or other drug use disorders 1, 3
• Family history: Ask about substance use disorders in first-degree relatives, particularly maternal opioid use which is linked to repeated prescription opioid use in offspring 1, 3

Psychiatric Comorbidities

• Mental health disorders: Screen for depression (present in 47% of OUD patients), anxiety, ADHD, and other psychiatric conditions, as these increase extended opioid usage risk 2-3 fold 3, 5
• Suicidal ideation: Specifically assess for current or past suicidal thoughts, as this is strongly associated with prescription opioid use disorders 4
• Adverse childhood experiences (ACEs): Document childhood trauma, abuse, or neglect, as higher ACE scores correlate with heroin use and NMPO use 6

Pain History

• Chronic pain conditions: Ask about persistent pain, as pediatric chronic pain is a risk factor for adult opioid misuse and 84.2% of adolescents cite pain relief as their primary motive for opioid misuse 3
• Prior pain treatment: Document whether the patient was denied prescription opioids for pain, as nearly 25% of young adults (age 16-25) denied opioids went on to pursue non-medical opioid use or heroin for self-medication 3

Demographic and Environmental Factors

• Age: Document current age, as 18-24 year-olds carry higher risk for opioid misuse 1
• Socioeconomic factors: Note neighborhood characteristics, education level, and access to healthcare, as these influence both chronic pain and opioid misuse risk 3

Validated Screening Tools to Administer

Use standardized instruments to minimize provider bias and ensure comprehensive assessment:

• ASSIST (Alcohol, Smoking and Substance Involvement Screening Test): Recommended by WHO for substance use risk stratification 1
• Opioid Risk Tool (ORT): Assigns sex-specific scores based on five risk factors (personal substance abuse history, family history, age, mental illness, childhood sexual abuse) to predict aberrant opioid use 1
• S2BI or BSTAD: Validated tools for screening substance use in young adults 3
• CRAFFT v2.0: Recommended for adolescents and young adults in primary care, emergency departments, and specialty clinics 3

Co-Occurring Mental Health Assessment

Given the 64.3% prevalence of any mental illness and 26.9% prevalence of serious mental illness in adults with OUD, systematically screen for:

• Depressive symptoms: Use standardized depression screening, as 47% of OUD patients have co-occurring depression 2, 5
• Anxiety disorders: Document symptoms of generalized anxiety, panic, social anxiety, or PTSD 3
• Affective regulation problems: Ask about emotional dysregulation, impulsivity, and executive control difficulties 3
• Other substance use disorders: Assess for co-occurring alcohol use disorder (26.4% prevalence), methamphetamine use disorder (10.6% prevalence), and cannabis use disorder 2

Communication Approach

Frame the assessment to reduce stigma and encourage honest reporting:

• Normalize the process: Explain that all patients are assessed for risk factors as universal precautions to protect them from harm and ensure safe treatment 1
• Use nonjudgmental language: Discuss results openly without moral judgment, emphasizing that assessment guides appropriate care 1
• Avoid confrontational questioning: Instead of asking "Don't you see your cocaine use is hurting your family?", ask "What do you like about using? What makes you think about stopping?" 3

Risk Stratification and Documentation

Based on assessment findings, stratify patients and plan monitoring:

• Low risk: Patients with few or no risk factors—reassess at least every 3 months 1
• Medium risk: Patients with some risk factors but no active aberrant behaviors—reassess more frequently than every 3 months 1
• High risk: Patients with multiple risk factors, aberrant drug-taking behaviors (injection, crushing), or active psychiatric instability—refer to providers with extensive addiction medicine experience 1

Document comprehensively:

• All identified risk factors 1
• Screening tool scores 1
• Treatment plan including monitoring frequency 1
• Functional impairment examples 1

Critical Pitfalls to Avoid

• Failing to screen universally: Screen during well-visits and when there are concerns, not just when suspicion is high, to minimize provider bias 3
• Missing diversion sources: Ask specifically about leftover opioids from family and friends' prescriptions, a common source for adolescent experimentation 3
• Overlooking pain as a driver: Recognize that inadequate pain treatment may drive patients to seek illicit opioids—address pain management needs alongside addiction treatment 3
• Underestimating psychiatric comorbidity: With 64.3% prevalence of mental illness in OUD patients, assume co-occurring conditions are present until proven otherwise 2
• Ignoring parental substance use: Maternal long-term opioid therapy is linked to repeated prescription opioid use in children—ask about household substance use 3

Treatment Planning Implications

Based on history findings, recognize that:

• Only 8.5% of adolescents needing substance use treatment receive it, and less than 2% of adolescents with OUD receive medication for opioid use disorder (MOUD) 3
• For patients over age 16 with opioid dependency, evidence-based treatment is buprenorphine/naloxone combined with behavioral interventions for minimum 52 weeks 3
• Only 24.5% of adults with OUD and any mental illness receive both mental health and substance use treatment services—comprehensive service delivery models addressing both conditions are urgently needed 2
• Adolescents and young adults struggle with treatment retention more than older adults, requiring enhanced engagement strategies 3