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## Complete Summary

#### GUIDELINE TITLE

Medication-assisted treatment for opioid addiction in opioid treatment
programs: Initial screening, admission procedures, and assessment
techniques.

#### BIBLIOGRAPHIC SOURCE(S)

Initial screening, admission procedures, and assessment techniques. In:
Batki SL, Kauffman JF, Marion I, Parrino MW, Woody GE, Center for
Substance Abuse Treatment (CSAT). Medication-assisted treatment for
opioid addiction in opioid treatment programs. Rockville (MD): Substance
Abuse and Mental Health Services Administration (SAMHSA); 2005. p.
43-61. (Treatment improvement protocol (TIP); no. 43).

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Opioid addiction

#### GUIDELINE CATEGORY

Evaluation\
Management\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Psychiatry\
Psychology

#### INTENDED USERS

Nurses\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers\
Substance Use Disorders Treatment Providers

#### GUIDELINE OBJECTIVE(S)

To describe screening and assessment procedures and important
considerations that might be made during and shortly after admission to
an opioid treatment program, as well as assessment techniques and
considerations that are important to ongoing medication-assisted
treatment

#### TARGET POPULATION

Patients with an addiction to opioids who are eligible for
medication-assisted treatment programs

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening**

1.  Crisis intervention

2.  Eligibility verification

3.  Clarification of the treatment alliance

4.  Patient education

5.  Identification of treatment barriers

6.  Screening of emergencies, including assessments of suicidality and
    violent behavior

**Admission to Opioid Treatment Program**

1.  Timely admission, waiting lists, and referrals

2.  Interim maintenance treatment

3.  Denial of admission

4.  Admission team training

5.  Information collection and dissemination

**Medical Assessment**

1.  Determination of opioid addiction and verification of admission
    eligibility

2.  History of nonopioid substance use and treatment

3.  Medical history

4.  Complete physical examination

5.  Laboratory tests including tests for syphilis, hepatitis,
    tuberculosis (TB), human immunodeficiency virus (HIV), sexually
    transmitted diseases, and recent drug use

6.  Women\'s health assessment

7.  Induction assessment

8.  Assessment of patient motivation for change

9.  Substance use assessment

10. Cultural and psychosocial assessment

    -   History or co-occurring disorders and current mental status

    -   Sociodemographic history

    -   Assessment of family and cultural background, relationships, and
        supports

    -   History of physical or sexual abuse

    -   Assessment of housing status and safety concerns

    -   Assessment of criminal history and legal status

    -   Assessment of insurance status

    -   Employment and military history

    -   Assessment of spirituality

    -   Assessment of sexual orientation and history

    -   Assessment of patients\' ability to manage money

    -   Assessment of patients\' recreational and leisure activities

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature search involved careful consideration of all relevant
clinical and health services research findings, practice experience, and
implementation requirements.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

After selecting a topic, Center for Substance Abuse Treatment (CSAT)
invites staff from pertinent Federal agencies and national organizations
to be members of a resource panel that recommends specific areas of
focus as well as resources that should be considered in developing the
content for the Treatment Improvement Protocols (TIP). These
recommendations are communicated to a consensus panel composed of
experts on the topic who have been nominated by their peers. This
consensus panel participates in a series of discussions. The information
and recommendations on which they reach consensus form the foundation of
the TIP. The members of each consensus panel represent substance abuse
treatment programs, hospitals, community health centers, counseling
programs, criminal justice and child welfare agencies, and private
practitioners. A panel chair (or co-chairs) ensures that the contents of
the TIP mirror the results of the group\'s collaboration.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A large and diverse group of experts closely reviews the draft document.
Once the changes recommended by these field reviewers have been
incorporated, the Treatment Improvement Protocol (TIP) is prepared for
publication, in print and on line.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Initial Screening**

**First Contact**

Staff members should be prepared to provide immediate, practical
information that helps potential applicants make decisions about
medication-assisted treatment for opioid addiction (MAT), including the
approximate length of time from first contact to admission, what to
expect during the admission process, and types of services offered.

**Goals of Initial Screening**

The consensus panel recommends the following goals for initial
screening:

-   *Crisis intervention*. Identification of and immediate assistance
    with crisis and emergency situations (see \"Screening of Emergencies
    and Need for Emergency Care\" below)

-   *Eligibility verification*. Assurance that an applicant satisfies
    Federal and State regulations and program criteria for admission to
    an opioid treatment program (OTP)

-   *Clarification of the treatment alliance*. Explanation of patient
    and program responsibilities

-   *Education*. Communication of essential information about MAT and
    OTP operations (e.g., dosing schedules, OTP hours, treatment
    requirements, addiction as a brain disease) and discussion of the
    benefits and drawbacks of MAT to help applicants make informed
    decisions about treatment

-   *Identification of treatment barriers*. Determination of factors
    that might hinder an applicant\'s ability to meet treatment
    requirements, for example, lack of childcare or transportation

Along with these primary goals, initial screening can begin to identify
other medical and psychosocial risk factors that could affect treatment,
including factors related to mental disorders; legal difficulties; other
substance use; and vocational, financial, transportation, and family
concerns. Cultural, ethnic, and spiritual factors that affect
communication and might affect treatment planning should be noted as
early as possible. Staff members should obtain enough information from
applicants to accommodate needs arising from any of these factors if
necessary.

**Screening of Emergencies and Need for Emergency Care**

The consensus panel recommends that providers develop medically,
legally, and ethically sound policies to address patient emergencies.
Emergencies can occur at any time but are most common during induction
to MAT and the acute treatment phase. In particular, patients who
exhibit symptoms that could jeopardize their or others\' safety should
be referred immediately for inpatient medical or psychiatric care. If
possible, staff members who conduct initial screening and assessment
should make appropriate referrals before applicants are admitted to an
OTP. Identifying and assessing emergencies may require staff familiarity
with the components of a mental health status examination (see
\"Psychosocial Assessment\" below).

*Suicidality*

Initial screening and periodic assessments should help determine whether
those indicating risks of suicide need additional services (e.g.,
hospitalization for protection or treatment, outpatient mental
treatment, or evaluation for antidepressant medication). See Exhibit 4-1
in the original guideline document for a list of suicide risk factors.

[Recommended Responses to Indicators of Suicidality]{.underline}

-   Be direct. Talk openly and matter-of-factly about suicide.

-   Be willing to listen. Allow expressions of feelings. Accept the
    feelings.

-   Be nonjudgmental. Don\'t debate whether suicide is right or wrong or
    feelings are good or bad. Don\'t lecture on the value of life.

-   Get involved. Become available. Show interest and support.

-   Don\'t dare an individual to do it.

-   Don\'t act shocked. This puts distance between the practitioner and
    the individual.

-   Don\'t be sworn to secrecy. Seek support.

-   Offer hope but not glib reassurances that alternatives are
    available.

-   Take action. Remove means, such as guns or stockpiled pills.

-   Get help from persons or agencies specializing in crisis
    intervention and suicide prevention.

*Homicidality and Threats of Violence*

Threats should be taken seriously. For example, if an individual with
knowledge of OTP procedures and schedules makes a threat, patterns of
interaction between staff and this individual should be shifted. It
might be necessary to change or stagger departure times, implement a
buddy system, or use an escort service. Counseling assignments can be
changed, or patients can be transferred to another OTP.

The consensus panel recommends that OTP staff members receive training
in recognizing and responding to the signs of potential patient
violence. OTPs should develop policies and procedures for homicide and
other violent situations. The OTP\'s policy on violence and threats of
violence should be explained at the beginning of treatment. Emergency
screening and assessment procedures should include the following:

-   Asking the patient questions specific to homicidal ideation,
    including thoughts, plans, gestures, or attempts in the past year;
    weapons charges; and previous arrests, restraining orders, or other
    legal procedures related to real or potential violence at home or
    the workplace.

-   Documenting violent incidents and diligent monitoring of these
    records to assess the nature and magnitude of workplace violence and
    to quantify risk. When a threat appears imminent, all legal, human
    resource, employee assistance, community mental health, and law
    enforcement resources should be readied to respond immediately.

**Admission Procedures and Initial Evaluation**

After initial applicant screening, the admission process should be
thorough and facilitate timely enrollment in the OTP. The admission
process should be designed to engage new patients positively while
screening for and assessing problems and needs that might affect MAT
interventions.

**Timely Admission, Waiting Lists, and Referrals**

The longer the delays between first contact, initial screening, and
admission and the more appointments required to complete these
procedures, the fewer the applicants who actually enter treatment.
Prompt, efficient orientation and evaluation contribute to the
therapeutic nature of the admission process.

If a program is at capacity, admitting staff should advise applicants
immediately of a waiting list and provide one or more referrals to
programs that can meet their treatment needs more quickly. A centralized
intake process across programs can facilitate the admission process,
particularly when applicants must be referred.

If an applicant goes willingly to another program for immediate
treatment but prefers admission to the original OTP, the admission
process should be completed and the applicant\'s name added to the
waiting list.

Patients who prefer to await treatment at the original site should be
added to the waiting list and contacted periodically to determine
whether they want to continue waiting or be referred. For individuals
who are ineligible, staff should assess the need for other acute
services and promptly make appropriate referrals. The consensus panel
recommends that each OTP establish criteria to decide which prequalified
patients should receive admission priority, especially when a program is
near capacity. For example, some programs offer high-priority admission
to pregnant women, addicted spouses of current patients, applicants with
human immunodeficiency virus (HIV) infection or other serious medical
conditions, or former patients who have tapered off maintenance
medication but subsequently require renewed treatment.

**Interim Maintenance Treatment**

For eligible individuals who cannot be admitted to a public or nonprofit
program for comprehensive maintenance services within a reasonable
geographic area and within 14 days of applying, Federal Regulations
provide for interim maintenance treatment, in which medication is
administered to patients at an OTP for up to 120 days without formal
screening or admission and with only minimal drug testing, assuming the
existence of reasonable criteria at the OTP to prioritize admissions.

**Denial of Admission**

Denial of admission to an OTP should be based on sound clinical
practices and the best interests of both the applicant and the OTP.
Admission denial should be considered, for example, if an applicant is
threatening or violent. Continuity of care should be considered, and
referral to more suitable programs should be the rule. Due process and
attention to applicant rights minimize the possibility that decisions to
deny admission to an OTP are abusive or arbitrary.

**Admission Team**

OTPs should have qualified, compassionate, well-trained
multidisciplinary teams that efficiently collect applicants\'
information and histories, evaluate their needs as patients, and orient
them to MAT. Team members should be cross-trained in treating addiction
and co-occurring disorders. Those conducting admission interviews should
be culturally competent, and their interactions with applicants should
not be stigmatizing. They also should be able to communicate OTP
policies and services and make appropriate referrals.

**Information Collection and Dissemination**

Collection of patient information and dissemination of program
information occur by various methods, such as by telephone; through a
receptionist; and through handbooks, information packets, and
questionnaires. Medical assessments (e.g., physical examinations, blood
work) and psychosocial assessments also are necessary to gather specific
types of information. Although collection procedures differ among OTPs,
the consensus panel recommends that the following types of information
be collected, documented, or communicated to patients:

-   *Treatment history*. An OTP should obtain a new patient\'s substance
    abuse treatment history, preferably from previous treatment
    providers, including information such as use of other substances
    while in treatment, dates and durations of treatment, patterns of
    success or failure, and reasons for discharge or dropout. Written
    consent from a patient is required to obtain information from other
    programs. (See below for details on other components to include in
    this history.)

-   *Orientation to MAT*. All patients should receive an orientation to
    MAT, generally extending over several sessions and including an
    explanation of treatment methods, options, and requirements and the
    roles and responsibilities of those involved. Each new patient also
    should receive a handbook (or other appropriate materials), written
    at an understandable level in the patient\'s first language if
    possible, that includes all relevant program-specific information
    needed to comply with treatment requirements. Patient orientation
    should be documented carefully for medical and legal reasons.
    Documentation should show that patients have been informed of all
    aspects of the multifaceted MAT process and its information
    requirements, including (1) the consent to treatment, (2) program
    recordkeeping and confidentiality requirements (e.g., who has access
    to records and when, who can divulge information without patient
    consent), (3) program rules, including patient rights, grievance
    procedures, and circumstances under which a patient can be
    discharged involuntarily, and (4) facility safety instructions
    (e.g., emergency exit routes). OTPs should require patients to sign
    or initial a form documenting their participation in the orientation
    process. Also, patients must receive and sign a written consent to
    treatment form, which is kept on file by the OTP (See Appendix 4-A
    of the original guideline document for an example of a standard
    consent form).

-   *Age of applicant*. Persons younger than age 18 must meet specific
    Federal and State requirements (at this writing, some States
    prohibit MAT for this group), and an OTP must secure parental or
    other guardian consent to start adolescents on MAT (see discussion
    below of exemptions from the Substance Abuse and Mental Health
    Services Administration\'s \[SAMHSA\'s\] 1-year dependence duration
    rule).

-   *Recovery environment*. A patient\'s living environment, including
    the social network, those living in the residence, and stability of
    housing, can support or jeopardize treatment.

-   *Suicide and other emergency risks*. (See above.)

-   *Substances of abuse*. A patient\'s substance abuse history should
    be recorded, focusing first on opioid use, including severity and
    age at onset of physical addiction, as well as use patterns over the
    past year, especially the previous 30 days. A baseline determination
    of current addiction should meet, to the extent possible, accepted
    medical criteria. Many people who are opioid addicted use other
    drugs and alcohol; this multiple substance use has definite
    implications for treatment outcomes (see section below entitled
    \"Substance Use Assessment\"). Therefore, screening and medical
    assessment also should identify and document nonopioid substance use
    and determine whether an alternative intervention (e.g., inpatient
    detoxification) is necessary or possible before an applicant is
    admitted to the OTP.

-   *Prescription drug and over-the-counter medication* use. All
    prescription drug and over-the-counter medication use should be
    identified. Procedures should be in place to determine any instances
    of misuse, overdose, or addiction, especially for psychiatric or
    pain medications. The potential for drug interactions, particularly
    with opioid treatment medications, should be noted.

-   *Method and level of opioid use*. The general frequency, amounts,
    and routes of opioid use should be recorded. If opioids are
    injected, the risk of communicable diseases (e.g., HIV/AIDS,
    hepatitis C, endocarditis) increases. Patient reporting helps
    providers assess patients\' substance addiction and tolerance
    levels, providing a starting point to prescribe appropriate
    treatment medication for stabilization).

-   *Pattern of daily preoccupation with opioids*. A patient\'s daily
    pattern of opioid abuse should be determined. Regular and frequent
    use to offset withdrawal is a clear indicator of physiological
    dependence. In addition, people who are opioid addicted spend
    increasing amounts of time and energy obtaining, using, and
    responding to the effects of these drugs.

-   *Compulsive behaviors*. Patients in MAT sometimes have other impulse
    control disorders. A treatment provider should assess behaviors such
    as compulsive gambling or sexual behavior to develop a comprehensive
    perspective on each patient.

-   *Patient motivation and reasons for seeking treatment*. Prospective
    patients typically present for treatment because they are in
    withdrawal and want relief. They often are preoccupied with whether
    and when they can receive medication. Because successful MAT entails
    not only short-term relief but a steady, long-term commitment,
    applicants should be asked why they are seeking treatment, why they
    chose MAT, and whether they fully understand all available treatment
    options and the nature of MAT. Negative attitudes toward MAT may
    reduce patient motivation. However, concerns about motivation should
    not delay admission unless applicants clearly seem ambivalent. In
    such cases, treatment providers and applicants can discuss the pros
    and cons of MAT. The consensus panel believes that identifying and
    addressing concerns about and stressing the benefits of MAT as early
    as possible are essential to long-term treatment retention and
    maintaining patient motivation for treatment.

-   *Patient personal recovery resources*. A patient\'s comments also
    can identify his or her recovery resources. These include comments
    on satisfaction with marital status and living arrangements; use of
    leisure time; problems with family members, friends, significant
    others, neighbors, and coworkers; the patient\'s view of the
    severity of these problems; insurance status; and employment,
    vocational, and educational status. Identification of patient
    strengths (e.g., stable employment, family support, spirituality,
    strong motivation for recovery) provides a basis for a focused,
    individualized, and effective treatment plan.

-   *Scheduling the next appointment*. Unless the program can provide
    assessment and admission on the same day, the next visit should be
    scheduled for as soon as possible. To facilitate an accurate
    diagnosis of opioid addiction and prompt administration of the
    initial dose of medication when other documentation of a patient\'s
    condition is unavailable, the applicant should be instructed to
    report to the OTP while in mild to moderate opioid withdrawal.

**Medical Assessment**

The results of medical assessment, including toxicology tests, other
laboratory results, and psychosocial assessment, usually are reviewed by
a program physician and then submitted to the medical director in
preparation for pharmacotherapy. Programs should minimize delay in
administering the first dose of medication because, in most cases,
applicants will present in some degree of opioid withdrawal.

**Determination of Opioid Addiction and Verification of Admission
Eligibility**

*Federal Regulations on Eligibility*

Federal regulations state that, in general, opioid pharmacotherapy is
appropriate for persons who currently are addicted to an opioid drug and
became addicted at least 1 year before admission. Documentation of past
addiction might include treatment records or a primary care physician\'s
report. When an applicant\'s status is uncertain, admission decisions
should be based on drug test results and patient consultations.

*Exemptions from SAMHSA\'s 1-year Dependence Duration Rule*

If appropriate, a program physician can invoke an exception to the
1-year addiction history requirement for patients released from
correctional facilities (within 6 months after release), pregnant
patients (program physician must certify pregnancy), and previously
treated patients (up to 2 years after discharge).

A person younger than 18 must have undergone at least two documented
attempts at detoxification or outpatient psychosocial treatment within
12 months to be eligible for maintenance treatment. A parent, a legal
guardian, or an adult designated by a relevant State authority must
consent in writing for an adolescent to participate in MAT. Patients
younger than 18 should receive age-appropriate treatments, ideally with
a separate treatment track (e.g., young adult groups).

*Cases of Uncertainty*

When absence of a treatment history or withdrawal symptoms creates
uncertainty about an applicant\'s eligibility, OTP staff should ask the
applicant for other means of verification, such as criminal records
involving use or possession of opioids or knowledge of such use by a
probation or parole officer. A notarized statement from a family or
clergy member who can attest to an individual\'s opioid abuse might be
feasible.

The consensus panel does not recommend use of a naloxone (Narcan®)
challenge test in cases of uncertainty. Physical dependence on opioids
can be demonstrated by less drastic measures. For example, a patient can
be observed for the effects of withdrawal after he or she has not used a
short-acting opioid for 6 to 8 hours. Administering a low dose of
methadone and then observing the patient also is appropriate.
Administering naloxone, although effective, can initiate severe
withdrawal, which the consensus panel believes is unnecessary. It also
requires invasive injection, and the effects can disrupt or jeopardize
prospects for a sound therapeutic relationship with the patient. The
panel recommends that naloxone be reserved to treat opioid overdose
emergencies.

**History and Extent of Nonopioid Substance Use and Treatment**

The extent and level of alcohol and nonopioid drug use and treatment
also should be determined, and decisions should be made about whether
these disorders can be managed safely during MAT (see \"Substance Use
Assessment\" below).

**Medical History**

A complete medical history should include organ system diagnoses and
treatments and family and psychosocial histories. It should cover
chronic or acute medical conditions such as diabetes, liver or renal
diseases, sickle cell trait or anemia, and chronic pulmonary disease.
Documentation of infectious diseases, including hepatitis, HIV/AIDS,
tuberculosis (TB), and sexually transmitted diseases (STDs), is
especially important. Staff should note patients\' susceptibility to
vaccine-preventable illnesses and any allergies and treatments or
medications received for other medical conditions. Women\'s medical
histories also should document previous pregnancies; types of delivery;
complications; current pregnancy status and involvement with prenatal
care; alcohol and drug use, including over-the-counter medications,
caffeine, and nicotine, before and during any pregnancies; and
incidences of sudden infant death syndrome.

**Complete Physical Examination**

Each patient must undergo a complete, fully documented physical
examination by the program physician, a primary care physician, or an
authorized health care professional under the direct supervision of the
program physician, before admission to the OTP. The full medical
examination, including the results of the serology and other tests, must
be documented in the patient\'s record within 14 days following
admission. States may have additional requirements, and OTPs must comply
with these requirements. The examination should cover major organ
systems and the patient\'s overall health status and should document
indications of infectious diseases; pulmonary, liver, and cardiac
abnormalities; dermatologic sequelae of addiction; vital signs; general
appearance of head, eyes, ears, nose, throat, chest, abdomen,
extremities, and skin; and physical evidence of injection drug use and
dependence, as well as the physician\'s clinical judgment of the extent
of physical dependence. Women should receive a pregnancy test and a
gynecological examination at the OTP site or by referral to a women\'s
health center. Again, the results of all tests, laboratory work, and
other processes related to the initial medical examination are to be
contained in the patient\'s file within 14 days following admission.

**Laboratory Tests**

Although Federal regulations no longer require OTPs to conduct a full
panel of laboratory tests, some States do. The consensus panel
recommends that laboratory tests include routine tests for syphilis,
hepatitis, tuberculosis (TB), and recent drug use. SAMHSA regulations
stipulate \"at least eight random drug abuse tests\" annually per
patient, performed according to accepted OTP practice. Given that some
drugs are metabolized extensively and excreted quickly, it is important
that analytic procedures provide the highest sensitivity for substances
of interest, such as breath testing for alcohol use.

*TB Testing*

All patients should undergo screening and medical examination for TB
every 12 months. Anergy panel tests should be administered to anergic
patients (those with diminished reactivity to certain antigens).
Patients who are immune system compromised might have a negative
purified protein derivative test, even with active infection. A chest x
ray or sputum analysis should be done if there is doubt. If a patient
has a positive TB test, medical staff should treat the patient
accordingly or refer him or her to a primary care clinic for treatment.

*Hepatitis Testing*

People who inject drugs are at high risk for hepatitis virus infection
and should be tested at admission to an OTP.

Any patients whose tests are negative for hepatitis A virus or hepatitis
B virus (HBV) infection should be vaccinated for these infections at the
OTP or by referral.

The consensus panel strongly recommends that hepatitis C virus (HCV)
diagnosis and referral be an integral component of initial MAT
assessment. Programs that do not offer onsite HCV antibody testing
should provide appropriate referrals.

*HIV Testing*

OTPs are required to provide adequate medical services, and the program
sponsor must be able to document that these services are fully and
reasonably available to patients. HIV testing on site or by referral,
with pretest and posttest counseling, is a recommended medical service.
OTPs should make HIV testing part of their medical services as
recommended by the Centers for Disease Control and Prevention. Medical
care and other supportive services can be offered if patients\' HIV and
HCV statuses are known early in treatment and monitored continuously.

OTPs performing rapid HIV tests should comply with the guidelines
provided in SAMHSA\'s Rapid HIV Testing Initiative
([www.samhsa.gov/HIVHep/rhti_factsheet.aspx](http://www.samhsa.gov/HIVHep/rhti_factsheet.aspx)).
As a preliminary positive test, positive results should be confirmed by
supplemental HIV testing. In addition, some States have other
requirements for laboratory testing in general and HIV testing
specifically.

*STD Testing*

Early testing for STDs in patients receiving MAT usually is a State
health requirement. All patients in MAT should receive serologic
screening for syphilis and, for women and symptomatic men, genital
cultures for gonorrhea and chlamydia. In the early stages of admission
and treatment, patients should be educated about the effects of STDs and
their correlation with other communicable diseases, such as HIV/AIDS and
hepatitis C, to increase patients\' knowledge of the ways they can avoid
these risks.

Documenting the sexual histories of heterosexual and lesbian, gay, and
bisexual (LGB) patients, in terms of timing of sexual encounters and
partners, is essential to determine their potential exposure to HCV,
HIV, and other STDs, as well as the risk of infection for other sexual
partners.

*Additional Drug Testing*

After initial drug testing, subsequent assessment should include further
review of urine, blood, oral fluid, or other drug test results. Ideally,
drug tests should be conducted regularly and randomly during treatment.

**Women\'s Health**

Women in MAT should receive information on their particular health
needs, for example, family planning, gynecological health, and
menopause. Women of childbearing age should be counseled on pregnancy
testing during admission before making decisions about detoxification.
Pregnancy testing, along with onsite access to or referral for family
planning services, should be available in all OTPs as part of an overall
women\'s health initiative.

**Induction Assessment**

A patient should be assessed at least daily during induction for signs
of overmedication or undermedication, and dose adjustments should be
made accordingly.

**Comprehensive Assessment**

Completion of induction marks the beginning of stabilization and
maintenance treatment and ongoing, comprehensive medical and
psychosocial assessment conducted over multiple sessions. This
assessment should include, but not be limited to, patient recollections
of and attitudes about previous substance abuse treatment; expectations
and motivation for treatment; level of support for a substance-free
lifestyle; history of physical or sexual abuse; military or combat
history; traumatic life events; and the cultural, religious, and
spiritual basis for any values and assumptions that might affect
treatment. This information should be included in an integrated summary
in which data are interpreted, patients\' strengths and problems are
noted, and a treatment plan is developed that matches each patient to
appropriate services.

Data should be collected in a respectful way, taking into consideration
a patient\'s current level of functioning.

SAMHSA regulations require that patients \"accepted for treatment at an
OTP shall be assessed initially and periodically by qualified personnel
to determine the most appropriate combination of services and
treatment.\" Treatment plans should be reviewed and updated, initially
every 90 days and, after 1 year, biannually or whenever changes affect a
patient\'s treatment outcomes. Ongoing monitoring should ensure that
services are received, interventions work, new problems are identified
and documented, and services are adjusted as problems are solved.
Patients\' views of their progress, as well as the treatment team\'s
assessment of patients\' responses to treatment, should be documented in
the treatment plan.

**Patient Motivation and Readiness for Change**

Patient motivation to engage in MAT is a predictor of early retention
and is associated with increased participation, positive treatment
outcomes, improved social adjustment, and successful treatment
referrals.

Starting with initial contact and continuing throughout treatment,
assessment should focus on patient motivation for change. OTP staff
members help patients move beyond past experiences (e.g., negative
relationships with staff, inadequate dosing) by focusing on making a
fresh start, letting go of old grievances, and identifying current
realities, ambivalence about change, and goals for the future. It often
is helpful to enlist recovering patients in motivational enhancement
activities.

**Substance Use Assessment**

As discussed previously, a patient\'s lifetime substance use and
treatment history should be documented thoroughly. The following areas
should be assessed:

-   Periods of abstinence (e.g., number, duration, circumstances)

-   Circumstances or events leading to relapse

-   Effects of substance use on physical, psychological, and emotional
    functioning

-   Changing patterns of substance use, withdrawal signs and symptoms,
    and medical sequelae.

Most patients with histories of multiple substance abuse fall into one
of three groups, which should be determined during assessment: those who
use multiple substances (1) to experience their psychoactive effects,
(2) to self-medicate for clinically evident reasons (e.g., back pain,
insomnia, headache, co-occurring disorders), or (3) to compensate for
inadequate treatment medication. Multiple substance use should be
identified and addressed as soon as possible because of the risk of
possible overdose for patients who continue to abuse drugs or alcohol
during treatment. Continued substance abuse while in MAT might indicate
that another treatment option is more appropriate. A challenge in
treating patients who abuse substances for clinically evident reasons is
to determine whether the patients are attempting to medicate
undiagnosed, misdiagnosed, or undertreated problems. If so, then
effectively addressing these related problems may reduce or eliminate
continuing drug or alcohol abuse and improve outcomes.

**Cultural Assessment**

A comprehensive assessment should include patients\' values and
assumptions; linguistic preferences; attitudes, practices, and beliefs
about health and well-being; spirituality and religion; and
communication patterns that might originate partly from cultural
traditions and heritage. Staff knowledge about diverse groups is
important for effective treatment services. Of particular importance are
experiences and coping mechanisms related to assimilation and
acculturation of groups into mainstream American culture that may affect
how they perceive substance abuse and MAT. Gathering pertinent
information often must rely on subjective sources (e.g., interviews and
questionnaires). Even so, staff members involved in screening and
assessment should be cautioned against making value judgments about
cultural or ethnic preferences or assumptions about \"average\"
middle-class American values and beliefs.

To the extent possible, patient preferences for staff members who share
their cultural identity should be honored. Multilingual educational
materials and displays of culturally diverse materials in the OTP help
patients feel more at ease when English is not their primary language.

**Psychosocial Assessment**

The components and objectives of psychosocial assessment also are
applicable to patients in MAT. A psychosocial assessment typically
identifies the relevant dynamics of patients\' lives and functioning
both before the onset of illness (e.g., depression, anxiety) and
currently. It identifies patients\' specific strengths and resources
(e.g., employment, supportive family relationships) as a basis for
focused, individualized, effective treatment planning.

*History of Co-Occurring Disorders and Current Mental Status*

Mental status assessments identify the threshold signs of co-occurring
disorders and require familiarity with the components of a mental status
examination (i.e., general appearance, behaviour, and speech; stream of
thought, thought content, and mental capacity; mood and affect; and
judgment and insight) as outlined in *Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision*. A mental status
assessment also should look for perceptual disturbances and cognitive
dysfunction.

Qualified professionals should train all staff members involved in
screening and assessment to recognize signs and symptoms of change in
patients\' mental status. This training should be ongoing. After
reviewing their observations with the program physician, staff members
should refer all patients still suspected of having co-occurring
disorders for psychiatric evaluation. This evaluation should identify
the types of co-occurring disorders and determine how they affect
patients\' comprehension, cognition, and psychomotor functioning.
Persistent neuropsychological problems warrant formal testing to
diagnose their type and severity and to guide treatment. Consultations
by psychologists or physicians should be requested or referrals made for
testing.

*Sociodemographic History*

Sociodemographic data about an applicant should include employment,
educational, legal, military, family, psychiatric, and medical
histories, as well as current information, and should be supplemented by
documents for identification, such as a driver\'s license, birth or
baptismal certificate, passport, Social Security card, Medicaid card,
public assistance card, or identification card from another substance
abuse treatment program.

*Family and Cultural Background, Relationships, and Supports*

The comprehensive assessment should include questions about family
relationships and problems, including any history of domestic violence,
sexual abuse, and mental disorders (see below). When possible, the
assessment should include input from relatives and significant others.
Because families with members who abuse substances have problems
directly linked to this substance abuse, at least one staff member
should be trained in family therapy or in making appropriate referrals
for this intervention.

During assessment, program staff should be sensitive to various family
types represented in the patient population. For example, programs
treating significant numbers of single parents should consider onsite
childcare programs.

Any counselor or treatment provider who might confront emergencies
related to child or spousal abuse should be trained in how to identify
and report these problems.

Staff members should be trained to listen and prepared to hear traumatic
stories and handle these situations, for example, by monitoring any
intense symptoms and seeking special assistance when necessary. Staff
should be able to identify individuals who exhibit certain signs and
symptoms associated with abuse (e.g., posttraumatic stress disorder
\[PTSD\]) and provide or coordinate immediate services to address it.

[Child abuse]{.underline}. All States require mandatory reporting of
child abuse by helping professionals including OTP staff\--particularly
State-licensed physicians, therapists, nurses, and social workers. Most
States require that this reporting be immediate and offer toll-free
numbers. Most also require that reports include the name and address of
a parent or caretaker, the type of abuse or neglect, and the name of the
alleged perpetrator. Failure to report indications of abuse that results
in injury to a child can lead to criminal charges, a civil suit, or loss
of professional licensure. Mandated reporters generally are immune from
liability for reports made in good faith that later are found to be
erroneous.

Staff members who suspect domestic violence should investigate
immediately whether a patient\'s children have been harmed. Inquiries
into possible child abuse can occur only after notice of the limitations
of confidentiality in MAT has been given to the patient, who must
acknowledge receipt of this notice in writing. Patients also must be
informed, during orientation and when otherwise applicable, that
substance abuse treatment providers are required to notify a children\'s
protective services agency if they suspect child abuse or neglect.

[Spousal or partner abuse]{.underline}. Generally, if a patient believes
that she or he is in imminent danger from a batterer, the treatment
provider should respond to this situation before addressing any others
and, if necessary, suspend the screening or assessment interview to do
so. He or she should refer a patient to a shelter, legal services, or a
domestic violence program if indicated. Providers should be familiar
with relevant Federal, State, and local regulations on domestic violence
and the legal resources available (e.g., restraining orders, duty to
warn, legal obligation to report threats and past crimes,
confidentiality).

[Recommended Procedures for Identifying and Addressing Domestic
Violence\*]{.underline}

-   Look for physical injuries, especially patterns of untreated
    injuries to the face, neck, throat, and breasts, which might become
    apparent during the initial physical examination.

-   Pay attention to other indicators: history of relapse or treatment
    noncompliance; inconsistent explanations for injuries and
    evasiveness; complications in pregnancy; possible stress- and
    anxiety-related illnesses and conditions; sad, depressed affect; or
    talk of suicide.

-   Fulfill legal obligations to report suspected child abuse, neglect,
    and domestic violence.

-   Never discuss a patient without the patient\'s permission;
    understand which types of subpoenas and warrants require that
    records be turned over to authorities.

-   Convey that there is no justification for battering and that
    substance abuse is no excuse.

-   Contact domestic violence experts when battery has been confirmed.

\*State laws may include other requirements

The following methods for exploring potential domestic violence
situations can be incorporated into effective assessment tools:

-   Always interview patients in private about domestic violence.

-   Begin with direct, broad questions and move to more specific ones;
    inquire how disagreements or conflicts are resolved (e.g., \"Do you
    want to hit \[him or her\] to make \[him or her\] see sense?\"); ask
    whether patients have trouble with anger or have done anything when
    angry that they regret; combine these questions with other types of
    lifestyle questions.

-   Ask about violence by using concrete examples and specific
    hypothetical situations rather than vague, conceptual questions.

-   Display information about domestic violence in public (e.g., waiting
    room) and private (e.g., restroom) locations.

-   Use opportunities during discussions (e.g., comments about marital
    conflict situations or poor communication with partners) to probe
    further.

-   Obtain as complete a description as possible of the physical,
    sexual, and psychological violence perpetrated by or on a patient
    recently; typically, those who commit domestic violence minimize,
    deny, or otherwise obscure their acts.

*History of Physical or Sexual Abuse*

Some patients enter an OTP with a history of physical or sexual abuse,
which frequently causes additional psychological distress. Information
about these types of abuse is important in treatment planning but not
always easily accessible using specific assessment tools, especially
early in treatment. Some patients with abuse histories might deny their
victimization. Many women are less likely to admit abuse to male
counselors. Male staff should know when to request a staff change for
counseling about physical or sexual abuse. Patients might not be ready
to address the problem, think it is unrelated to substance abuse, or be
ashamed. Gathering information from them about abuse, therefore,
requires extreme care and respect during screening and assessment. Once
patients are stabilized and their practical needs are addressed,
counseling by qualified treatment providers can focus on this problem.

*Peer Relations and Support*

The extent of social deterioration, interpersonal loss, and isolation
that patients have experienced should be documented thoroughly during
screening and assessment. Assessment of a patient\'s support systems,
including past participation in mutual-help groups (e.g., Alcoholics
Anonymous, Methadone Anonymous \[MA\]), is critical to identifying peer
support networks that provide positive relationships and enhance
treatment outcomes. Some 12-Step groups are ill-informed about MAT and
may be unaware of the treatment goals of MAT and less than supportive;
in these cases, providers should help patients identify other sources of
support (e.g., MA groups) and encourage continued development of some
type of peer support network.

*Housing Status and Safety Concerns*

Based on year 2000 estimates, approximately 10 percent of patients in
MAT are homeless or living as transients when admitted to treatment.
Moreover, those who are not homeless often live with people who are
addicted or in areas where substance use is common. In the opinion of
the consensus panel, early intervention to arrange safe, permanent
shelter for these patients should be a high priority, and a patient\'s
shelter needs should be ascertained quickly during screening and
assessment. OTPs should establish special support services to help
patients secure appropriate living arrangements, such as referral
agreements with housing agencies or other programs to locate housing
that addresses the special needs of homeless patients.

*Criminal History and Legal Status*

Assessment may involve exploring personal circumstances such as child
custody and related obligations. In the consensus panel\'s experience,
many patients ignore legal problems during periods of substance use, but
these problems pose a serious threat to recovery. In addition, a
patient\'s arrest record, including age at first arrest, arrest
frequency, nature of offenses, criminal involvement during childhood,
and life involvement with the criminal justice system, should be
clarified.

*Insurance Status*

Patients\' resources to cover treatment costs should be determined
during screening and assessment. Often they are uninsured or have not
explored their eligibility for payment assistance. The consensus panel
believes that OTPs are responsible for helping patients explore payment
options so that they have access to a full range of treatment services,
including medical care, while ensuring payment to the OTP.

In situations of inadequate funding or patient ineligibility for funds,
another source of payment should be identified. OTP staff can assist
patients in applying for public assistance or inquiring whether personal
insurance will reimburse MAT costs. Counselors can help patients make
decisions about involving their insurance companies and address fears
that employers will find out about their substance use or that benefits
for health care will be denied.

*Employment History*

Another important component of psychosocial assessment is a patient\'s
employment history. Based on year 2000 estimates, only 20 percent of
patients in MAT were employed when admitted to an OTP. Until they are
stabilized, employed patients often experience substance-related
difficulties at the workplace, including lack of concentration,
tardiness and absences, inability to get along with co-workers,
on-the-job accidents, and increased claims for workers\' compensation.
Early identification of these difficulties can help staff and patients
create a more effective treatment plan.

Patients who are employed often are reluctant to enter residential
treatment or take the time to become stabilized on medication; however,
most of these patients would take medical or other leave time if they
were hospitalized for other illnesses, and they should be encouraged to
take their addiction as seriously. A physician\'s note recommending time
off work for some period might help, but it should be on letterhead that
does not reference drug treatment.

*Military or Other Service History*

A patient\'s military or other service history can highlight valuable
areas in treatment planning. In particular, was military service
generally a positive or negative experience? If the former, treatment
providers can help patients identify areas of strength of personal
achievement, such as the ability to cope under stress, receipt of medals
for service accomplishments, and honorable discharge; patients can learn
to build on past strengths in current challenging situations and to
progress in treatment. If the latter, providers should review patients\'
negative military experiences, including loss of friends and loved ones,
onset of substance use, war-related injuries, chronic pain, PTSD, and
co-occurring disorders (e.g., depression). This information might
indicate patterns of behavior that continue to affect recovery.

Patients\' military history also might reveal their eligibility for
medical and treatment resources through U.S. Department of Veterans
Affairs programs and hospitals or social service agencies.

*Spirituality*

A patient\'s spirituality can be an important treatment resource, and
persons recovering from addiction often experience increased interest in
the spiritual aspects of their lives. Staff should assess patients\'
connections with religious institutions because these institutions often
provide a sense of belonging that is valuable in the rehabilitative
process.

OTPs should assess spiritual resources adequately. Counselors and other
mental health professionals could benefit from training in patient
spirituality if it is difficult for them to explore.

*Sexual Orientation and History*

The assessment and treatment needs of heterosexual and LGB populations
are similar and should focus on stopping the substance abuse that
interferes with patients\' well-being. Assessment of risk factors
associated with sexual encounters and partners is essential. What often
differs for an LGB population is the importance of assessing patients\'
sexual or gender orientation concerns, such as their feelings about
their sexual orientation. OTP staff should pay strict attention to
confidentiality concerns for LGB patients because they may be at
increased risk of legal or other actions affecting employment, housing,
or child custody. Treatment modalities and programs should be accessible
to all groups, and programs providing ancillary services should be
sensitive to the special needs of all patients regardless of sexual
orientation.

*Patients\' Ability to Manage Money*

Financial status and money management skills should be assessed to help
patients understand their fiscal strengths and weaknesses as they become
stabilized. Patients often need assistance to adjust to loss of income
caused by reduced criminal activity and develop skills that enhance
their legitimate earning power.

*Recreational and Leisure Activities*

Recreational and leisure activities are important in recovery;
therefore, assessment should determine any positive activities in which
patients have participated before or during periods of substance use.
Identifying existing recreational and leisure time preferences and
gaining exposure to new ones can be significant steps in developing a
recovery-oriented lifestyle.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Recommendations are based on a combination of clinical experience and
research-based evidence.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate screening, admission, and assessment of patients undergoing
medication-assisted treatment for opioid addiction

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The opinions expressed herein are the views of the consensus panel
members and do not necessarily reflect the official position of Center
for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA), or Department of Health and Human
Services (DHHS). No official support of or endorsement by CSAT, SAMHSA,
or DHHS for these opinions or for particular instruments, software, or
resources described in this document is intended or should be inferred.
The guidelines in this document should not be considered substitutes for
individualized client care and treatment decisions.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Chapter 14, Administrative Considerations, in the original guideline
document, covers the challenging administrative aspects of managing and
staffing the complex and dynamic environment of an opioid treatment
program (OTP). Successful treatment outcomes depend on the competence,
values, and attitudes of staff members. To develop and retain a stable
team of treatment personnel, program administrators must recruit and
hire qualified, capable, culturally sensitive individuals; offer
competitive salaries and benefit packages; and provide good supervision
and ongoing training. Implementing community relations and community
education efforts is important for opioid treatment programs. Outreach
and educational efforts can dispel misconceptions about
medication-assisted treatment for opioid addiction and people in
recovery. Finally, the chapter provides a framework for gathering and
analyzing program performance data. Program evaluation contributes to
improved treatment services by enabling administrators to base changes
in services on evidence of what works. Evaluation also serves as a way
to educate and influence policymakers and public and private payers.

Refer to Chapter 14 in the original guideline document for full details
(see \"Companion Documents\" field in this summary).

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Initial screening, admission procedures, and assessment techniques. In:
Batki SL, Kauffman JF, Marion I, Parrino MW, Woody GE, Center for
Substance Abuse Treatment (CSAT). Medication-assisted treatment for
opioid addiction in opioid treatment programs. Rockville (MD): Substance
Abuse and Mental Health Services Administration (SAMHSA); 2005. p.
43-61. (Treatment improvement protocol (TIP); no. 43).

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005

#### GUIDELINE DEVELOPER(S)

Substance Abuse and Mental Health Services Administration (U.S.) -
Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Treatment Improvement Protocol (TIP) Series 43 Consensus Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Steven L. Batki, MD (*Chair*), Professor and Director
of Research, Department of Psychiatry, SUNY Upstate Medical University,
Syracuse, New York; Janice F. Kauffman, RN, MPH, LADC, CAS (*Co-Chair*),
Vice President, Addiction Treatment Services, North Charles Foundation,
Inc., Cambridge, Massachusetts; Director, Addiction Psychiatry Service,
Department of Psychiatry, Brigham and Women\'s Hospital, Boston,
Massachusetts; Assistant Professor of Psychiatry, Harvard Medical
School, Boston, Massachusetts; Ira Marion, MA (*Co-Chair*), Executive
Director, Division of Substance Abuse, Albert Einstein College of
Medicine, Bronx, New York; Mark W. Parrino, MPA (*Co-Chair*), President,
American Association for the Treatment of Opioid Dependence, New York,
New York; George E. Woody, MD (*Co-Chair*), Treatment Research
Institute, University of Pennsylvania/MIRECC Philadelphia VAMC,
Philadelphia, Pennsylvania; Patrick Abbott, MD, Medical Director, Center
on Alcoholism, Substance Abuse, and Addictions, University of New
Mexico, Albuquerque, New Mexico; Leslie Amass, PhD, Principal
Investigator, Friends Research Institute, Inc., Los Angeles, California;
Hector D. Barreto, MD, MPH, Medical Director, Center for Drug-Free
Living, Orlando, Florida; Michael D. Couty, Director, Division of
Alcohol and Drug Abuse, Missouri Department of Mental Health, Jefferson
City, Missouri; Vashti Jude Forbes, RN, BC, MSN, LCDC, Associate
Director, Substance Abuse and Specialized Services, Austin Travis County
Mental Health and Mental Retardation Center, Austin, Texas; Ron Jackson,
MSW, Executive Director, Evergreen Treatment Services, Seattle,
Washington; Karol A. Kaltenbach, PhD, Director, Maternal Addiction
Treatment Education and Research, Jefferson Medical College, Thomas
Jefferson University, Philadelphia, Pennsylvania; Judith Martin, MD,
FASAM, Medical Director, 14th Street Clinic & Medical Group, Inc.,
Oakland, California; Violanda T. Nunez, MSW, Executive Director,
Ayudantes, Inc., Santa Fe, New Mexico; J. Thomas Payte, MD, Medical
Director, Drug Dependence Associates, San Antonio, Texas; Norma J.
Reppucci, RN, Director, Operations for Eastern MA and NH, Community
Substance Abuse Centers, Malden, Massachusetts; Yong S. Song, PhD,
Assistant Clinical Professor and Program, Director, Opiate Treatment
Outpatient Program, University of California, San Francisco, San
Francisco, California; Jo L. Sotheran, PhD, Associate Research
Scientist, Mailman School of Public Health, Columbia University, New
York, New York; Trusandra Taylor, MD, Physician Advisor, Parkside
Recovery Methadone Maintenance, Philadelphia, Pennsylvania

*Editorial Advisory Board*: John D. Crowley, Crowley Associates, Elgin,
South Carolina; Herbert D. Kleber, MD, Professor of Psychiatry, Columbia
University College of Physicians & Surgeons, New York, New York; Stewart
B. Leavitt, PhD, Leavitt Medical Communications, Glenview, Illinois;
Jocelyn Sue Woods, MA, President, National Alliance of Methadone
Advocates, New York, New York; Joan Zweben, PhD, Executive Director,
14th Street Clinic & Medical Group, Inc., East Bay Community Recovery
Project, Berkeley, California

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the National Clearinghouse for Alcohol and
Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20852.
Publications may be ordered from [NCADI\'s Web
site](http://store.health.org/catalog/SC_Itemlist.aspx) or by calling
(800) 729-6686 (United States only).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Executive summary. Medication-assisted treatment for opioid
    addiction in opioid treatment programs. p. xvii-xx. (Treatment
    improvement protocol (TIP); no. 43).

-   Introduction. Medication-assisted treatment for opioid addiction in
    opioid treatment programs. p. 1-10. (Treatment improvement protocol
    (TIP); no. 43).

-   History of medication-assisted treatment for opioid addiction.
    Medication-assisted treatment for opioid addiction in opioid
    treatment programs. p. 11-23. (Treatment improvement protocol (TIP);
    no. 43).

-   Pharmacology of medications used to treat opioid addiction.
    Medication-assisted treatment for opioid addiction in opioid
    treatment programs. p. 25-42. (Treatment improvement protocol (TIP);
    no. 43).

-   Administrative considerations. Medication-assisted treatment for
    opioid addiction in opioid treatment programs. p. 225-240.
    (Treatment improvement protocol (TIP); no. 43).

-   Appendix D: Ethical considerations in MAT. Medication-assisted
    treatment for opioid addiction in opioid treatment programs. p.
    297-304. (Treatment improvement protocol (TIP); no. 43).

Electronic copies: Available from the [National Library of Medicine
Health Services/Technology Assessment (HSTAT) Web
site](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.82676).
Also available in Portable Document Format (PDF) from [SAMHSA\'s
National Clearinghouse for Alcohol and Drug Information (NCADI) Web
site](http://ncadi.samhsa.gov/media/Prevline/pdfs/bkd524.pdf).

The following are also available:

-   Knowledge Application Program. KAP keys for clinicians. Based on TIP
    43: Medication-assisted treatment for opioid addiction in opioid
    treatment programs. Rockville (MD): Substance Abuse and Mental
    Health Services Administration (SAMHSA); 2005. 20 p. Electronic
    copies: Available in Portable Document Format (PDF) from the [SAMHSA
    Web site](http://kap.samhsa.gov/products/tools/keys/pdfs/KK_43.pdf).

-   Quick guide for clinicians. Based on TIP 43: Medication-assisted
    treatment for opioid addiction in opioid treatment programs.
    Rockville (MD): Substance Abuse and Mental Health Services
    Administration (SAMHSA); 2005. 39 p. Electronic copies: Available in
    Portable Document Format (PDF) from the [SAMHSA Web
    site](http://kap.samhsa.gov/products/tools/cl-guides/pdfs/QGC_43.pdf).

Additionally, an example of Standard Consent to Opioid Maintenance
Treatment form can be found in Appendix 4-A of the [original guideline
document](http://ncadi.samhsa.gov/media/Prevline/pdfs/bkd524.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 21, 2005. The
information was verified by the guideline developer on January 23, 2006.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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