• Summary
• Introduction
• Assessment length and setting
• Setting the scene
• Methadone assessment checklist
• Going through the assessment checklist
• General information
• Drug-using history
• Life history
• Current situation
• Objective support for your assessment

Summary

• Comprehensive assessment is a key component in effective treatment of opiate users.

• Methadone is a controlled drug with high dependency potential and a low lethal dose, therefore it should only be prescribed where there is certain knowledge of recent opiate use and where there is a care plan which includes clear treatment goals.

• If there is any doubt at all in the mind of a prescriber as to the wisdom of prescribing it is important to remember that there is almost certainly more risk in mis-prescribing than in not prescribing.

• Specialist advice and assessment is usually available to non-specialist services.

Introduction
Assessment of opiate use is not an exact science. The outcome of an assessment will depend on the interpretation by the assessor of the:

• Client's description of their feelings
• History the client gives
• The amount, type, route of administration and frequency of drugs the client says they are using
• Objective signs of use (injection marks, urinalysis etc.)
• Signs of intoxication/withdrawal.

The assessment will be affected by:

• Who is assessing
• The type of agency in which the assessment is taking place
• The services available
• The degree of specialist knowledge the assessor has.

The objectives of an assessment for the suitability of methadone treatment are the same whatever the setting, namely to determine:

• Is the person an opiate user?
• Have they been previously notified to the Home Office?
• Are they already receiving methadone treatment from another prescriber?
• Is methadone an appropriate treatment?

and to give the client an understanding of:

• The treatment options available
• The difference between the experience of heroin and methadone.

Subsequent sections look at the issues of determining the length of treatment and starting methadone dose.

The headings below cover the core components of a good initial assessment (see checklist below) and describe some of the tools that can be used to help decide on treatment goals and, later, to measure their effectiveness.

Assessment length and setting
People who are requesting help with their opiate problems are usually assessed either:

• In the community
• As a day patient of a drug service or hospital unit
• As a hospital/drug unit in-patient over a few days.

Community assessments
The majority of assessments are done in the community. Most community assessments are done over one or more one-hour sessions with the client. They do not usually require the client to be observed withdrawing from opiates or be supervised taking a 'test dose' of methadone.

Day patient and in-patient assessments
In-patient and day assessments are more expensive and require specialist staff but they can be more objective because they give the opportunity for the client to be assessed:

• Very closely
• Over a long period of time
• By a multidisciplinary team
• Experiencing withdrawal symptoms
• Following the administration of methadone.

They also allow more time to develop a therapeutic relationship, give health education information and to discuss issues such as injecting practice and HIV.

This type of assessment may be indicated when:

• There is some doubt about the level of opiate use
• The person is requesting a high dose of methadone
• There are complicating factors such as heavy poly drug use or medical problems.

Setting the scene
It is important to give the client an understanding of the purpose of the assessment process right from the outset. Most initial community assessments are one hour long.

It is important that the client knows at the start:

• How long the interview is likely to last
• How it will be structured
• The purpose of any notes you take
• Your policies on confidentiality
• What the treatment options might be.

This will help the client disclose the information you need to make the assessment and will prevent them from having unrealistic expectations of what you are able to do at the end of the assessment.

Why are you doing the assessment?
Explain that the key functions of the assessment are to get:

• A clear picture of the problems besetting the user

and to ensure that your response:

• Is appropriate/helpful
• Will not make them dependent on a larger dose of methadone than necessary.

Will I get a methadone prescription?
This is usually the client's overriding concern and it may manifest itself as anxiety, anger or behaviours such as threatening to commit suicide or break the law to obtain supplies, etc. Sometimes clients will say that if they do not get a prescription it will be the worker's/doctor's responsibility if they go out and overdose or break into a pharmacy etc. to obtain supplies. However the drug use and associated behaviour is the responsibility of the client - not you. Clarity about the framework within which you are both working will minimise these behaviours because it will be clear that they will not increase the likelihood of the outcome the client wants. It is useful to tell the client that it is your intention to help them as best you can, and that if methadone is to be prescribed you would want it to be enough so that it will be of some help to them. If you are not the prescriber it is important to explain what your relationship with the prescriber is and what role your assessment plays in the prescribing decision.

A client who knows that you are willing to prescribe or arrange a methadone prescription, if you think it is the right thing to do, is much more likely to relax and co-operate. It is therefore important to advise the client of the timescale of response to a request for prescribing.

Never allow yourself to be pressurised into a course of action you are unhappy about and make it clear that you retain the right to make a clinical judgement to refuse to commence or to withdraw treatment if there is evidence that it is not therapeutic.

Honesty
Try to reassure the client that you are not going to halve all their reports of their recent drug use so there is no need for them to double everything. This may come as a big surprise and, of course, they may not entirely believe you so exaggeration may still be a feature of the history you are given.

It is still important to try and establish an honest, trusting relationship with the client while looking at a range of indicators and asking questions about recent drug use in a number of ways.

Confidentiality
Clients need to know that you do not have a hot-line to the local police station, their parents, etc. If people are going to give informed consent to the passing on of personal information they need to know exactly what confidentiality means to you and your agency.

It is a good idea to do this at both the beginning and the end of the interview - at the beginning in broad terms and at the end you can discuss in detail what information needs to be passed on, to whom and how that is going to be done.

There is further discussion about confidentiality in Section 10: Practical issues in methadone prescribing.

Using a standard assessment format
Each agency should have its own written assessment format. This allows you to make sure that:

• You do not miss anything
• All clients get the same assessment, regardless of who carries it out
• You have a written record of what you did and why you did it.

The checklist below can be used as a basis for an assessment.

The Home Office and/or local database notification forms can be used to give a swift documented record of an individual's current drug use - but they are no substitute for a prepared assessment process and format.

A number of assessment and diagnosis tools have been developed over the years. These include:

• Leeds Dependence Questionnaire⁸¹
• The Substance Abuse Assessment Questionnaire⁸²
• The Severity of Opiate Dependence Questionnaire (SODQ)⁸³
• The Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition.⁸⁴

These tools, when skilfully applied, provide very accurate, standardised formats for assessing the level of dependence. They are not all very worker or client 'friendly'. Unless workers are familiar with the format the gains made in having standard information are lost in a more impersonal interaction. However some, such as the Leeds Dependence Questionnaire, are quick, easy and reliable tools.

Methadone assessment checklist

• Assessor
• Assessment date
• Urine speciment taken for drug screen (yes/no)
• Name
• Date of birth
• Age
• Address
• Telephone number (and correspondence address/telephone number if different)
• General practitioner
• Who referred the client to your agency
• Other agencies involved with the client, e.g. social services, probation, etc
• Current legal situation - outstanding prosecution, etc

• Curent drug(s) used
• Amount(s) currently used
• Primary drug
• Other drugs
• Alcohol use - units per day and week
• Pattern of use
• History of injecting
• Age of first use
• Drug used
• History and pattern
• Periods of abstinence/causes of relapse

• Life history
• Employment history
• Mental health history
• Physical health history

• Events leading to referral
• Motivation to attend
• Current family situation
• Client's summary of problems
• Client's hypothesis of reasons for drug/alcohol use and service/help requested
• Overall impression
• Conclusion

Going through the assessment checklist
An assessment of someone requesting a methadone prescription should cover the following areas:

• General information
• Drug-using history
• Life history
• Current physical, social and psychological situations
• Reasons for seeking help
• Conclusions.

This section goes through the assessment checklist above outlining the information you need and how it can be gathered under the headings, which are not just straightforward questions.

There may appear to be a lot of questions. This is partly because drug users are not always forthcoming about all aspects of their life. This is not surprising - many have had unfortunate experiences at the hands of health and other helping professionals. So if you do not ask you may not find out - until it is too late!

General information
Clients will often present with high levels of anxiety. The taking of basic information can help relax and engage them in the assessment process.

Other agencies involved
Knowledge of which other agencies are involved can both help you understand the complexity of the client's problems and plan with the client what liaison, if any, you are going to have with those agencies.

Current legal situation
Fear of a custodial sentence is often a motivator for seeking help, which needs to be identified early on in the care plan as it can dictate the time frame within which you are working. It is therefore important to get details of any:

• Charges faced
• Pending court cases
• Probation orders.

Drug-using history

Current drug(s) used
Opiate users often use a combination of other drugs alongside their heroin use. They may not consider their benzodiazepine use significant or relevant enough to disclose unless asked directly about it. It is also important to ask if they are receiving any other prescribed medication.

Primary drug used
This is important, particularly in the case of opiate use/assessment for methadone prescribing. Obviously if you are thinking of methadone prescribing you need to be sure that it is the right thing to do. There is little point in giving methadone to someone who is:

• Not dependent on opiates
• Using mainly non-opiate drugs such as amphetamine, cocaine or alcohol.

Establishing current levels of opiate use
Current opiate use is a key area to assess correctly because if a decision is taken to prescribe methadone the dose will, to a large extent, be determined by the amount of opiates the client is thought to be taking. This is discussed further in Section 9: Getting the starting dose right.

In a system that relies largely on judgements based upon what people say, there are several factors that can complicate the assessment. Clients often:

• Presume that decisions on the amount of methadone they receive will be based on their current opiate consumption
• Think their account will be believed to be exaggerated and therefore exaggerate accordingly to compensate
• Represent current levels of use according to the amount they use on 'good' days.

For this reason the current levels of opiate use need to be returned to several times, and in several ways, during the course of the assessment. A model for doing this in 4 'phases' during the assessment is outlined below.

During the course of the assessment - as the client becomes more relaxed - go through the following points in groups such as the ones suggested below. In these lists the word heroin can be substituted with the person's opiate(s) of choice.

Phase 1

• How much heroin do you take a day?
• How much did you take yesterday?
• How much, on average, do you take in a week?
• How much have you had so far today?

Phase 2

• How many days a week do you take heroin?
• How do you feel after you've taken heroin?
• How long after you've taken some does it take before you feel rough again?
• What withdrawal symptoms are you experiencing now?
• What do the withdrawals feel like?

Phase 3

• How much do you buy at a time?
• How much do you pay per gram?
• How much is your habit costing you a day?
• How much did you take on the day you had most last week?
• How many days in the last week did you have any opiates?

Phase 4

• How much do you spend a week on heroin?
• How much heroin can you get by with on your worst days?
• How often do you score in a day?
• When was the last time you had an opiate free day?
• Have there been times when you have stopped all opiate use for more than 3 days?

It will be difficult for someone who is not an opiate user to answer all the above questions consistently and accurately. If your client is an opiate user the pattern of their answers will usually give you a good idea of the level of their opiate use because it is difficult without preparation to consistently lie across such a broad range of questions.

Alcohol use
A minority of people presenting for methadone treatment have significant alcohol problems. For some the main attraction of methadone is its ability to potentiate the action of alcohol.

Where this may be the case treatment aims need to be clearly specified.

The interplay between opiate and alcohol use needs to be clearly understood by both the worker and client - and disproportionate attention to opiates (and inappropriate methadone prescribing) need to be avoided.

For many opiate users the process of understanding their alcohol use in terms of units consumed and potential harm is a useful exercise.

Pattern of drug use
As well as how much the person is taking you also need a broader picture of their current pattern of drug use.

Is the drug use:

• Experimental: being tried out
• Recreational: used intermittently and with some control
• Compulsive: dependent daily use with physical and psychological dependence and little perceived control over the use?

Most people who present are in the latter category and methadone treatment is unlikely to be of value for people in the former groups.

Is the heroin:

• Smoked
• Injected
• or both?

Do they take heroin:

• With friends
• At the dealers
• Alone
• Don't care as long as they've got some?

How much at a time?

• Quantities of the drug used at each use
• How long is each drug-using episode
• How long does a purchase last
• Can they save some for the morning?

History of injecting
Injecting is the riskiest way of introducing a drug into the body. It by-passes the body's natural defences by putting the substance straight into the bloodstream. People who inject are taking more risks than people who do not, the risks being infection, overdose and transmission of disease to or from themselves.

The risks are not only concerned with sharing syringes, and a supplement to any assessment for methadone prescribing should be a detailed assessment of injecting practices and an opportunity for the user to discuss this issue in detail.

An inspection of all injection sites should be carried out both to verify that they exist and to check for infection and other complications of injecting.

Drug-taking history
It is important to get a perspective of the current opiate use in terms of the person's drug-taking history.

Ask about any other drugs they have taken, starting with their first ever drug use. Chart each drug with the following details:

• Age of first use
• Pattern of use from then on
• Reasons why it was first taken
• Reasons why they continued to use it
• How its use related to other drugs used
• When (if) its use was stopped and why.

If the client has had times free from each drug ask:

• How long were these periods?
• What symptoms of withdrawal did you experience?
• Did you replace the drug with anything else?
• What started you using it again?

A history of drug-free times and the causes of relapse can be a great help in planning care and strategies for the future.

A pattern of switching dependence from one drug to another (particularly alcohol and benzodiazepines) is likely to reduce the chances of methadone prescribing being an effective intervention in the medium or long term if the client is likely to continue with this pattern.

Life history
It is important that methadone treatment is seen in the context of wider psycho-social help. The taking of a comprehensive history demonstrates that dealing with issues arising from the past may be part of the treatment.

Clearly the amount and quality of information gathered when taking the life history will be determined by the state of mind of the client and the quality of the relationship that can be built in the first session. If taking a full history is not appropriate or possible in the first session then it is useful to return to it at a later date.

As with any counselling or psychiatric assessment, open questioning which will allow the client to tell you about their background is important. Areas covered would normally include:

• Early childhood
• Parental relationships
• Siblings
• Moves and schooling
• Abuse (childhood and/or recent)
• Relationships
• Marriage
• Employment/unemployment

and the other areas described below.

The criminal 'justice' system
A significant minority of people who are opiate dependent will have a history of court appearances. These range from cautions for possession, convictions for supply through to major prison sentences for drugs offences or related crimes such as:

• Theft
• Burglary
• Violent offences (these may have implications for case management).

Taking a history of offences, prosecutions and sentences may also provide a useful opportunity to assess the importance of problem drinking as offences committed under the influence of alcohol suggest that this may be a potential problem area.

Mental health
Any history of depression, psychosis or other mental health problems is of importance as these indicate areas in which future problems may arise.

Also check for previous admissions to psychiatric hospitals or out-patient clinics, suicide attempts and overdoses. See also Section 11: Prescribing for groups with special needs.

Physical health
Many opiate users have low incomes, lead unhealthy lifestyles and have little contact with health care services. Health difficulties they encounter may be directly related to the drugs themselves or may be a consequence of their lifestyle.

It is important to ask about past and present health problems and be aware of possible future ones during the assessment. Usually a general question about health will be enough to prompt the client, but in particular be alert for the following:

• HIV/AIDS - everyone involved in the care of drug users should be familiar with the signs and symptoms of HIV-related illness
• Impaired liver function which may be caused by hepatitis B or C or alcohol use
• Untreated chest infections - common in opiate users as the cough reflex is suppressed by opiates and most are smokers
• Weight loss
• Psychiatric/neurological problems e.g. epilepsy, head injury or psychotic episodes
• Digestion: constipation is common in opiate users
• Localised infections such as abscesses
• Poor dental health
• Pregnancy.

Do not forget that drug users may have the complication of underlying illness or injury masked by the analgesic effects of opiates. Doctors assessing drug users should always include a physical examination.

Current situation

Events leading to referral
There are several topics to cover under this heading that will help you build up a picture of what has brought this person to seek help and what services will best help them address their problems.

Motivation to attend
Determining why someone is seeking help now is a key issue as it will underpin your understanding of what changes they want to make and why, which in turn informs your decision about what treatment aims to pursue.

Current family situation
An understanding of the family and other relationships that affect the user is important in offering appropriate help. Questions such as the following can all help in gaining an understanding of the relationships affecting the client:

• How has the drug use affected the family?
• Have there been breakdowns of relationships because of the use?
• What do the family think about the use?
• Are they worried or frightened?
• Do they need help and support in their own right?
• Can they offer support or assistance?

Child care
Issues around drug-using parents are also covered in Section 11: Prescribing for groups with special needs - Care of people with responsibility for young people.

It is important to ascertain at assessment whether clients have responsibility for the care of any young people, and if so, their ability to discharge that responsibility.

Current social situation
In terms of a social life:

• Do they have friends who are not in the drug scene or does life revolve around drugs and other drug users?
• Do they still have a job or prospects of one?
• Do they have any interests or rewarding activities other than drugs?
• Are they able to form and sustain relationships?

Answers to these questions will give you a good insight into the importance that the clients place on drugs in their lives and to the support structures they have in place if they are looking at stopping using drugs.

Finances
The financial health of the client is often a key indicator. Many people sell drugs to support their consumption, and many become involved with crime and/or get into debt.

A moderate to heavy UK consumer of illicit heroin using say 1 gram per day may need to generate at least £300 cash per week, or they may obtain drugs by other means, such as working in the sex industry or by exchanging goods for drugs.

The client may have worries and concerns about drug and/or other 'normal' household debts that they need to discuss.

Objective support for your assessment
It is important to arrange, as soon as possible, for a urine sample to be sent to the pathology lab for a drug screen or to use a portable test at the time of assessment.

An opiate-positive urine test in the notes of everyone with a methadone prescription is an essential safeguard for all concerned. Urinalysis is discussed further in Section 10: Practical issues in methadone prescribing.

Liaison with other agencies involved, with the consent of the client, can provide useful corroboration of the history and can help you plan a co-ordinated approach.

Checking injection sites for 'track marks' is good evidence of injecting although some people, through careful injection technique, manage to inject leaving virtually no trace on the skin. A record of the number and extent of injection sites along with a description of the associated bruising and inflammation can be useful in determining the success of treatment.

Observation of the client in withdrawals and post-methadone dose also provides a relatively objective measure of opiate dependence. However many opiate users (especially those who have been using illicit methadone) do not produce text book observable withdrawal symptoms even 18 hours after their last dose.