Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence

2.2 Assessment for treatment with methadone

Page last updated: August 2003

Initial assessment procedures are similar for all opioid users seeking treatment. A comprehensive assessment of the patient's drug use, medical, psychological, and social conditions, previous treatment history and current treatment goals should be conducted and documented. Specific attention should be given to assessment of dependence and tolerance, and the indications, contraindications, and precautions for methadone treatment (see section 2.1). Obtain corroborative evidence of identity and aspects of the history relating to drug use, medical and psychiatric conditions to clarify any inconsistencies between physical examination findings and reported history. Accuracy of clinical assessment may be improved by using corroborating evidence such as urine tests and examination of veins for evidence of injecting drug use.

Corroborative evidence of dependence should also be obtained. The best evidence is observed signs of opioid withdrawal (spontaneous or precipitated by naloxone challenge), or a verifiable history of previous treatment for opioid dependence (detoxification or maintenance).

The initial assessment will result in an initial management plan which can be implemented directly. However, extra information will also need to be gathered at subsequent reviews so that more comprehensive treatment plans can be developed.

Key features of the assessment

  • Opioid use

    • Opioids used, quantity, frequency, route of administration, duration of current episode of use, time of last use and use in the last 3 days
    • Severity of dependence (see Section 2.1, Appendix 3)
    • Age of commencement, age of regular use, age of dependence, timing and duration of periods of abstinence
    • Episodes of overdose

  • Other drug use including alcohol, illegal and prescribed drugs, current medications

  • Health status

    • Diseases from drug use (blood borne viruses, other)
    • Intercurrent health conditions (psychiatric, general)

  • Psychosocial status Top of page

    • Legal
    • Social – employment, education/vocational skills, housing, financial, family.
    • Psychological – mood, affect, cognition.

  • Past treatment

    • Where
    • When
    • Periods of abstinence
    • Degrees of success/acceptance of treatment

  • Selection of treatment

    • Motivation for treatment
    • Trigger for seeking treatment
    • Patient goals for treatment episode
    • Stage of change (see Appendix 6 for further reading)

  • Physical examination

    • Observation of clinical signs related to drug use (needle track marks, intoxication, withdrawal – see Appendix 2 & Appendix 3)
    • Evidence of medical problems (eg liver disease – jaundice, ascites, encephalopathy)

  • Investigations

    • Urine drug screening tests may be indicated if there are concerns about the accuracy of the drug history and diagnosis and may also be useful to confirm benzodiazepine and other drug use.
    • Investigations for HIV and hepatitis B and C if indicated