Signs and Symptoms of Polysubstance Abuse
Patients with opioid use disorders commonly have problems with other substances as well; in fact, polysubstance abuse is considered the norm rather than the exception (Patrick, 2003).
Among opioid addicts, cocaine and alcohol are the most frequently abused substances (Strain, 2002). Many also commonly misuse other prescription medications.
The signs and symptoms of polysubstance abuse include some of the same indicators for drug use in general.
Patients may or may not be dependent upon the various substances they are abusing, so it is important for you to assess the entire range of a patient's substance use.
Try these 4 main approaches for assessing opioid dependent patients for other substance abuse:
- Screening instruments: MAST, DAST, CAGE-AID, AUDIT
- Clinical assessments: ask patient directly, ask family members
- Structured interviews: DSM SCID (Structured Clinical Interview for DSM Axis I Disorders)
- Laboratory tests: urine samples, preferably tested on-site or via a lab with a quick turn-around time so that you can address results with the patient as soon as possible
Being able to accurately gauge the current drug use by patients enrolled in a substance abuse program is essential; self-reports, family member reports, observation of attitude alteration, and behavior changes are generally insufficient. Therefore, urine testing is an integral part of the office-based buprenorphine treatment program and should be explained as such to patients during the initial discussion of the treatment rules and expectations. Patients must understand that this, too, is an ongoing part of their treatment.
Because it is an ongoing part of buprenorphine treatment, the provider must make several fundamental decisions about urine testing procedures.
|Timing of Testing||
A plan for urine testing must include a decision between random and scheduled testing. Random testing dramatically increases the probability of detecting illicit drug usage: Patients can no longer plan their drug usage around a testing schedule. A possible method of implementing random testing may require patients to call the office on scheduled days to ascertain whether that particular day will be a testing day.
|Frequency of Testing||
The provider must also consider the frequency of testing. In methadone maintenance programs, more frequent testing provides a more complete picture of drug use habits, thus helping to direct treatment (Wasserman et al., 1999). SAMHSA (2004) recommends administering monthly urine tests to patients being treated for opioid dependence. These tests should screen not only for continued opioid use but also for use of other illicit drugs (SAMHSA, 2004).
Collection monitoring is an important consideration in urine testing -- direct observation is the most definite mechanism of observation. By requiring the patient to leave coats, purses, etc., outside the bathroom and having a same-sex observer present, the chances of obtaining a doctored sample are minimized. If direct observation is not desired or possible, thermometers or testing machines that analyze urine temperature are an appropriate substitute. If patients have a substantial commute, providers may consider testing the patient in a location outside the office, although similar monitoring considerations must be taken into account at collection times. To prevent patients from tampering with their samples using available materials, collection facilities could lack soap dispensers and cleaning agents (NIDA, 1986). If dilution of urine is a concern, consider dyeing toilet water or installing a chemical toilet (NIDA, 1986).
|On-Site Versus Off-Site Testing||
Providers must decide whether on-site or off-site urine testing is the more appropriate choice for their treatment program. Each has its advantages. Advantages of on-site testing include less handling of the specimen, which will reduce the potential for mistakes, a "greater sense of confidentiality," and quicker results (NIDA, 1986). However, in most cases, a positive result should be confirmed using a different testing technique at an off-site laboratory (NIDA, 1986). Advantages of off-site testing include immediate access to additional tests to confirm a positive initial result, which also decreases potential mistakes, and expertise of the laboratory staff (NIDA, 1986). If testing is to be done off-site, specimens should be stored in a secure (locked) location until they are shipped (NIDA, 1986). Regardless of where analysis is done, be sure to secure all sampling accoutrements, such as cups, lids, and labels.
Urine testing for opioids can be done either by immunoassay or by laboratory-based, drug-specific identification using gas chromatography, mass spectrometry, high-phase liquid chromatography, or a similar technique. Immunoassays are fast, easy to use, and reliably detect any natural opioids (codeine, morphine, heroin) that are present. However, immunoassays often do not detect semisynthetic (oxycodone, buprenorphine) and synthetic (fentanyl) opioids (Gourlay et al., 2002). While methadone is a synthetic opioid, immunoassays have been developed specifically to detect it (SAMHSA, 2004). Drug-specific identification is more time consuming and detects only one drug per test, but it is reliable for all drugs (Gourlay et al., 2002).
One of the most commonly used standardized screening tools for detecting drug use problems is the CAGE-AID, a variation on the CAGE instrument that was originally created to screen for alcohol use. Brown et al., (1998) modified the CAGE questionnaire to add screening for drug use (AID stands for "adapted to include drugs"). The authors were able to obtain 70.9% sensitivity and 75.7% specificity with this modified scale.
Each letter in the acronym CAGE represents one question in the 4-item scale:
|C||Cut down -- Have you ever felt you ought to cut down on your drinking or drug use?|
|A||Annoyed -- Have people annoyed you by criticizing your drinking or drug use?|
|G||Guilty -- Have you ever felt bad or guilty about your drinking or drug use?|
|E||Eye-opener -- Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?|