December 6, 2017

What happens when an opioid-dependent person seeks treatment for the first time?

Different opioid addiction treatments work best for different people.  When a patient with an opioid use problem seeks help in an outpatient office, the physician will ask questions to find out more about his or her unique needs. He or she may ask confidential questions about:

  • Why a patient is seeking treatment
  • What substance(s) a patient is using
  • How often they use
  • The good and bad effects of the substance in their life
  • How their day-to-day life is affected by the substance
  • If any other emotional symptoms are present (depression, anxiety, etc.)
  • If there is a present crisis
  • The patient’s past drug or alcohol use
  • Any past treatments or periods of abstinence
  • The patient’s past medical history, current medications, and family and social history

Labs such as urine toxicology may also be done to test for the presence of opioids in the patient’s body. With these facts, a physician can help the patient to sort out the pros and cons of seeking treatment and stopping use of opioid drug(s). The patient and their doctor may then decide on a treatment that would work best for them, based on the patient’s needs, safety, and local resources. The patient’s finances, insurance, criminal justice status, past responses to treatments, and any co-occurring psychiatric disorders may also be considered.[1]

Adolescents and Young Adults: CRAFFT Screening

When an adolescent or young adult visits his or her doctor, the CRAFFT questions can help evaluate the risk for substance abuse problems.[2]These questions are used all over the world, and are very effective at evaluating a young person’s risk of problems with substance abuse.[3] The CRAFFT questions can also be used at home by a young person or the family to help evaluate risk or to decide if medical help is needed. PART 1 During the past year, did you:

  1. Drink any alcohol(more than a few sips)?
  2. Smoke any marijuana or hashish?
  3. Use anything elseto get high? (“Anything else” includes illegal drugs, over-the-counter or prescription medicines, or anything that you sniff or “huff.”)

PART 2 If the answer is “yes” to any of the first 3 questions, the following questions are used: (If the answer is “no” to all of the first 3 questions, only the first CAR question will apply.)

C R A F F T
Yes/No C Have you ever ridden in a CAR driven by someone (including yourself) who was “high,” or had been using alcohol or other drugs?
Yes/No R Do you ever use alcohol or other drugs to RELAX, feel better about yourself, or fit in?
Yes/No A Do you ever use alcohol or other drugs while you are ALONE?
Yes/No F Do you ever FORGET things you did while using alcohol or drugs?
Yes/No F Do your FAMILY or FRIENDS ever tell you that you should cut down on drinking or drug use?
Yes/No T Have you ever gotten into TROUBLE while you were using alcohol or drugs?

What does my CRAFFT score mean? 2 or more “yes” answers to the CRAFFT questions suggest that a young person is at high risk for substance abuse problems and/ or dangerous behavior. A young person who can answer “yes” to 2 or more CRAFFT questions should seek medical help as soon as possible. If the young person is already at a doctor’s office, further questions should be asked to see if treatment is necessary. These questions cannot diagnose a substance abuse disorder, but can help patients and doctors decide if further steps should be taken.

Adults: CAGE Questions

The CAGE questions are often used to screen for alcohol abuse in adults. However, they can also help identify other substance abuse problems.[4] These questions include: Have you ever felt you needed to CUT DOWN on substance use? A Have people ANNOYED you by criticizing your substance use? G Have you ever felt GUILTY about substance use? E Have you ever felt that you needed a drug first thing in the morning (EYE-OPENER)? Other “red flags” that primary care doctor look for to detect substance abuse problems in adults include:[5]

  • Frequent absences from school or work
  • Frequent accidental injuries
  • Depression
  • Anxiety
  • Sleep problems
  • Sexual dysfunction
  • Digestive problems, like stomach pain, diarrhea, constipation, or weight changes
Urine Drug Tests

There are many different ways to test for the presence of opioid drugs in the body. Urine, blood, hair, saliva, sweat, and nails (toenails and fingernails) can all be used in different types of laboratory drug testing. However, urine samples are used most often, because they are easier to obtain. Opioid drugs and their metabolites, or breakdown products, are often concentrated in the urine after making their way through the body. A general “screening” test can test for the presence of opioid drugs or their metabolites (the substances into which some drugs are broken down in the body). More specific tests can also be done to test for the presence of specific drugs or to confirm the results of earlier tests. What can doctors tell from a urine drug test? A urine sample can be tested for the presence of many different substances in the body, from opioid drugs to marijuana, cocaine, PCP, amphetamines, and/or benzodiazepines. Drugs can usually be detected in a urine sample within 1-2 days of use. However, detection times vary widely among different substances. For example, evidence of heroin use can be found in the urine up to 48 hours after last use, and evidence of methadone can be found for 3 days. Long-term marijuana use can be detected for up to 30 days. [6] Urine drug tests can tell doctors that a person has used a substance within a certain time period. Urine drug tests cannot tell doctors how much of a substance a person has used, or how they used it (inhaled, injected, or taken by mouth.) False positive tests can occur. Since some opioids are either derived from or similar to naturally occurring substances in the opium poppy seed, eating poppy-seed cookies or bagels prior to testing has caused false-positive results only in very sensitive tests. The use of prescription opioid pain relievers or certain antibiotics like rifampin, rifampicin, or quinolones can also cause false-positive urine tests for opioids. These possibilities should be discussed with a physician prior to testing. Benefits of Frequent Urine Drug Testing During an initial assessment and periodically throughout treatment, patients may be asked to provide a urine sample in the clinic. Patients are always encouraged to truthfully relate any drug use or relapse to their doctors before this sample is tested. Clinics require urine testing to provide accountability to patients. Frequent testing has been shown to improve a patient’s chances of sticking with treatment.[7] Drug testing is also helpful to keep patients safe: some addiction treatments like methadone and buprenorphine can be very dangerous when taken along with other drugs. If patients have relapsed to additional illicit drug use while using MAT, physicians need to know.


[1] Greenfield, S. F., & Hennessy, G. (2008). Assessment of the Patient. In M Galanter & H Kleber (Ed.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.

[2] The CRAFFT Screening Tool. (2009). Retrieved July 8, 2014, from http://www.ceasar-boston.org/CRAFFT/index.php

[3] Pilowsky, D. J., & Wu, L. T. (2013). Screening instruments for substance use and brief interventions targeting adolescents in primary care: a literature review. Addict Behav. May 38(5), 2146-53.

[4] Mersy, D. J. (2003). Recognition of Alcohol and Substance Abuse. Am Fam Physician. Apr 1;67(7), 1529-1532.

[5] Mersy, 2003.

[6] Moeller, K. E., Lee, K. C., & Kissack, J. C.  (2008). Urine drug screening: practical guide for clinicians. Mayo Clin Proc., Jan 83(1), 66-76.

[7] Yee, D. A., Hughes, M. M., Guo, A. Y., Barakat, N. H., Tse, S. A., Ma, J. D., Best, B. M., & Atavee, R. S. (2014). Observation of improved adherence with frequent urine drug testing in patients with pain. J. Opioid Manag. Jan;83(1), 66-76.