Addiction Medicine Initial Assessment

Initial Assessment Note

Patient Identification

Name: Thabo Mokoena Age: 34 years Gender: Male SA ID: 9203125184083 DOB: 12/03/1992 File Number: GP-784291-03 Referral Source: Family (accompanied by mother) Date and Time of Assessment: 10/04/2026 at 09:30

Presenting Complaint

Pt presents requesting help to stop smoking nyaope and drinking alcohol. Reports being "tired of living on the street and stealing from family." Goal is to complete medical detoxification, enter inpatient rehabilitation, and rebuild family relationships.

Substance Use History

• Nyaope (heroin/cannabis/antiretroviral mixture): Onset age 26 (8-year duration). Uses 5–6 bags daily via smoking ("chasing"). Last use: 10/04/2026 at 06:00. Triggers: peer pressure, boredom, withdrawal avoidance. Consequences: job loss, estrangement from family, Petty theft (2 previous arrests by SAPS, cases withdrawn). Attempted to quit "cold turkey" at home x 3; unable to tolerate withdrawal symptoms.
• Alcohol: Onset age 16. Drinks 2–3 x 750 mL bottles of beer on weekends, increasing to daily when nyaope is unavailable. Last use: 08/04/2026.
• Cannabis (dagga): Onset age 15. Smoked 2 joints daily until age 26, when he transitioned to nyaope.
• Methamphetamine (tik): Denies use.

Past Treatment and Relapse History

• 1x public inpatient detoxification and 6-week rehabilitation admission in 2023.
• Placed on methadone 20 mg PO daily during 2023 detox, tapered over 10 days; no maintenance therapy.
• Relapsed 2 months post-discharge due to unemployment and returning to the same peer group.
• No prior psychiatric admissions.

Medical and Psychiatric History

• HIV positive (diagnosed 2021); defaulted ART 4 months ago due to active substance use.
• Pulmonary TB in 2022: completed 6-month regimen, declared cured.
• Mild Major Depressive Disorder (diagnosed 2023 at local clinic).
• History of blunt head trauma in 2020 (assault); no LOC, no residual neurological deficits.

Medications and Allergies

• Current medications: Defaulted tenofovir disoproxil fumarate / lamivudine / dolutegravir 300 mg / 300 mg / 50 mg PO daily; defaulted fluoxetine 20 mg PO daily.
• Allergies: Penicillin (generalised maculopapular rash).

Physical and Mental State Examination

• Vitals: BP 135/85 mmHg, HR 98 bpm, RR 18 breaths/min, Temp 36.8 °C, Weight 56 kg.
• Physical: Cachectic, mild bilateral conjunctival pallor. Rhinorrhoea, piloerection, and mild resting tremor noted. Chest clear to auscultation. No track marks (smokes substances).
• MSE: Alert, oriented x 3 (time, place, person). Unkempt, dressed in worn clothing, cooperative. Speech normal rate and volume. Mood "depressed and anxious," affect constricted. Thought form linear; content preoccupied with withdrawal symptoms and guilt; no delusions or hallucinations. Insight fair, judgement impaired by addiction.

Risk Assessment

• Withdrawal severity: COWS score 13 (moderate opioid withdrawal). CIWA-Ar score 4 (minimal alcohol withdrawal).
• Suicide/Self-harm: Passive death wishes ("sometimes wish I wouldn't wake up"), denies active suicidal ideation, intent, or plan. No prior attempts.
• Overdose risk: Moderate to high if relapsing post-detox due to reduced tolerance.
• Psychosocial/Legal: Living in an informal backyard structure; family support conditional on engaging in treatment. No current pending SAPS charges. No history of aggression or harm to others.

Diagnosis

• DSM-5: Opioid Use Disorder, Severe (ICD-10: F11.20) in early withdrawal.
• DSM-5: Alcohol Use Disorder, Mild (ICD-10: F10.10).
• DSM-5: Major Depressive Disorder, single episode, mild (ICD-10: F32.0).
• ICD-10: B24 (Unspecified human immunodeficiency virus [HIV] disease - treatment defaulter).

Management Plan

• Medical stabilisation: Refer to medical officer for outpatient opioid withdrawal management (initiate methadone 20 mg PO daily or symptomatic relief with hyoscine butylbromide 10 mg PO TID PRN, loperamide 4 mg PO stat then 2 mg PRN, and diazepam 5 mg PO nocte x 3 days) and baseline bloods (FBC, U&E, LFT, CD4, HIV viral load).
• ART re-initiation: Refer back to local CHC to restart tenofovir disoproxil fumarate / lamivudine / dolutegravir 300 mg / 300 mg / 50 mg PO daily and fluoxetine 20 mg PO mane once medically stable.
• Psychosocial intervention: Weekly individual CBT and motivational interviewing sessions with Counselling Psychologist; include mother in collateral family session on 17/04/2026.
• Harm reduction: Provided overdose education (especially regarding reduced tolerance post-abstinence) and safe sex counselling.
• Referrals: Referred to Social Work for state inpatient rehabilitation application and grant-in-aid assessment.
• Follow-up: Review in psychology clinic on 17/04/2026 at 10:00.