The assessment is meant to comply with provisions of federal law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:
42 CFR 8.12(f) Required Services. Under federal law, the following are “required services” that must be provided by an Opioid Treatment Program (OTP).
OTPs must provide adequate medical, counseling, vocational, educational, and other assessment and treatment services. (Emphasis added.) Any assessments or treatments not directly provided at the facility must be assured via a formal documented agreement with the appropriate community providers.
Assessment begins during program admission and continues throughout treatment. Its purpose is to address the whole health and well-being of the patient (emphasis added). Assessment begins with a personal substance use history, physical examination, laboratory evaluation, and determination of disease morbidity.
All individuals who meet OTP admission criteria must receive a complete, fully documented physical evaluation (emphasis added) prior to admission to the OTP. The purpose of the initial medical evaluation is to confirm the diagnosis of opioid use disorder and identify co-occurring medical and psychiatric conditions that may make medication-assisted treatment unsafe, limit its effectiveness, influence the selection of pharmacotherapy, or require prompt medical attention.
Screening should be conducted for common co-occurring conditions even if the patient has no personal history of them. Screening should establish the risk of undiagnosed conditions such as Hepatitis C, the human immunodeficiency virus (HIV), sexually transmitted infections (STIs), cardio-pulmonary disease, and sleep apnea in order to determine what further diagnostic testing such as laboratory studies, a cardiogram, and others are needed.
Initial toxicology tests are a part of the admission process. At a minimum, admission samples are tested for opioids, methadone, buprenorphine, amphetamines, cocaine, marijuana, and benzodiazepines. If there is a history of prescription opioid analgesic abuse, an expanded toxicology panel that includes these opioids should be administered.
Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP (SMA). Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Accessed May 3, 2021 from Federal Guidelines for Opioid Treatment Programs (samhsa.gov)