Addiction Medicine Initial Evaluation Note

Identifying Information

Marcus Vance is a 34-year-old male presenting for an initial evaluation of opioid use disorder and major depressive disorder. He resides in a rented apartment in Chicago with his girlfriend and their rescue dog, and he works full-time as an HVAC technician.

Assessment

General Assessment

The patient presents with severe opioid use disorder and moderate recurrent major depressive disorder, supported by a two-year history of daily intranasal illicit fentanyl use, marked tolerance, withdrawal symptoms upon cessation, and persistent anhedonia and low mood. Biopsychosocial vulnerabilities include a strong family history of substance use, chronic lower back pain from a workplace injury, and untreated depressive symptoms. Current stressors include financial strain from purchasing illicit opioids and fear of losing his employment. Protective factors include stable housing, a supportive romantic partner, steady employment, and high internal motivation for recovery. Likely barriers to recovery include ongoing exposure to triggers via a coworker who uses substances and severe cravings. Treatment priorities are immediate initiation of buprenorphine/naloxone for withdrawal and craving management, alongside harm reduction education and mood stabilization.

Nicotine Assessment

The patient smokes 0.5 packs of cigarettes per day and uses a nicotine vape intermittently. He is currently pre-contemplative regarding smoking cessation, wishing to focus entirely on opioid abstinence first; nicotine replacement therapy was offered and deferred for future consideration.

Risk Assessment

The patient has a persistently increased risk of harm to self or others because of: severe daily intranasal fentanyl use with high risk of accidental overdose, history of one prior non-fatal opioid overdose six months ago, comorbid major depressive disorder, and a remote suicide attempt via overdose at age 22. These risks are reduced by: explicit denial of current suicidal or homicidal thoughts, plans, or intent; active readiness and commitment to MAT; future-focused thinking regarding career advancement; supportive partner in the home; stable housing; steady employment; and explicit denial of access to firearms.

Diagnoses

• Opioid Use Disorder, Severe (DSM-5 304.00 / F11.20) – Meets 8/11 criteria (tolerance, withdrawal, using larger amounts, inability to cut down, excessive time spent obtaining, cravings, role failure at work, continued use despite interpersonal problems). COWS score: 14 (moderate withdrawal).
• Major Depressive Disorder, Recurrent, Moderate (DSM-5 296.32 / F33.1) – Meets criteria with depressed mood, anhedonia, insomnia, fatigue, and guilt over the past 2 months. PHQ-9 score: 15.
• Tobacco Use Disorder, Moderate (DSM-5 305.1 / F17.200).

Plan

• Order urine drug screen (UDS) with fentanyl confirmation, CBC, CMP, hepatic function panel, HIV 1/2 antigen/antibody screen, Hepatitis C antibody with reflex to RNA, and Hepatitis B panel.
• START buprenorphine/naloxone (Suboxone®) 8 mg / 2 mg sublingual film BID on 14/05/2024 (instructed to take 4 mg / 1 mg now, repeat in 2 hours if withdrawal persists, up to 16 mg / 4 mg total daily).
• START naloxone (Narcan®) 4 mg/0.1 mL intranasal spray, 1 spray into one nostril PRN suspected overdose, prescribed on 14/05/2024.
• CONTINUE escitalopram (Lexapro®) 10 mg PO daily; INCREASE escitalopram (Lexapro®) to 20 mg PO daily starting 15/05/2024. -START hydroxyzine hydrochloride (Atarax®) 25 mg PO Q6H PRN anxiety/withdrawal symptoms on 14/05/2024.
• Initiate weekly individual CBT and motivational interviewing focused on relapse prevention and trigger management.
• Obtained consent to speak with partner, Sarah Jenkins, to provide naloxone administration training and discuss home safety sweep to remove drug paraphernalia.
• RTC in 1 week (21/05/2024 at 10:00 America/Chicago) for MAT induction follow-up and repeat UDS; referred to Intensive Outpatient Program (IOP) and local SMART Recovery meetings.

Reported History

Past Medical History

• Chronic mechanical low back pain (L4-L5 disc herniation, 2021)
• Essential hypertension

Medications

• Escitalopram (Lexapro®) 10 mg PO daily
• Lisinopril (Prinivil®) 10 mg PO daily
• Ibuprofen (Advil®) 400 mg PO PRN back pain

Past Psychiatric History

• Psychiatric Diagnoses: Major Depressive Disorder, diagnosed at age 21.
• Psychiatric Hospitalizations: One inpatient admission in 2012 (age 22) at Northwestern Memorial Hospital for 5 days following an intentional acetaminophen overdose.
• Outpatient treatment: Saw an outpatient psychiatrist intermittently from 2012 to 2016; currently prescribed escitalopram by PCP.
• Suicide Attempts: One attempt in 2012 via intentional overdose of OTC analgesics following a relationship breakup.
• Self Harm: Denies history of non-suicidal self-injury (cutting, burning).

Family History

• Family Psychiatric Diagnoses: Mother with Major Depressive Disorder and Generalized Anxiety Disorder.
• Family Psychiatric Hospitalizations: Maternal uncle hospitalized multiple times for Bipolar I Disorder.
• Family Completed Suicide: Maternal uncle died by suicide (hanging) at age 45.
• Family Substance Use: Father with severe Alcohol Use Disorder; older brother in remission from Opioid Use Disorder.

Social History

• Living Situation: Rents a two-bedroom apartment with his girlfriend of 4 years and their dog.
• Relationship Status: Unmarried, in a committed relationship for 4 years.
• Children: None.
• School: High school graduate; completed a 2-year vocational HVAC certification program.
• Income: Earns approximately $65,000 annually as a full-time commercial HVAC technician.
• Abuse, Neglect, Trauma: Witnessed frequent verbal and physical domestic arguments between parents during childhood due to father's alcohol use.
• Domestic Violence: Denies past or current intimate partner violence as victim or perpetrator.
• Legal History: One arrest in 2019 for misdemeanor possession of a controlled substance; charges dropped following court-mandated diversion program.
• Access to weapons: Denies owning or having access to firearms in the home.

Substance Use History

Treatment

• Residential Treatment for Substance Use: Completed a 28-day inpatient rehabilitation program at Gateway Foundation in 2022; maintained sobriety for 4 months post-discharge.
• Outpatient Treatment for Substance Use: Attended outpatient group therapy briefly in 2022 after residential rehab, but discontinued due to work schedule conflicts.

Substance Use

• Opioids: Initiated use with prescribed hydrocodone/paracetamol (Norco®) in 2021 after back injury. Transitioned to illicit pressed oxycodone ("M30") pills containing fentanyl 2 years ago. Currently uses 4–5 pills intranasally daily. Last use was 18 hours ago (13/05/2024 at 16:00). Denies IV use.
• Benzodiazepines: Used illicit alprazolam (Xanax®) sporadically in his 20s; denies use in the past 3 years.
• Cocaine: Tried intranasally a few times at parties in his early 20s; last use > 8 years ago.
• Methamphetamine: Denies lifetime use.
• Prescribed Stimulants: Used unprescribed mixed amphetamine salts (Adderall®) a handful of times in trade school; denies current use.
• Alcohol: Drinks 2–3 beers socially on weekends; last drink was 2 weeks ago. No history of withdrawal.
• Marijuana: Smokes 1 joint on weekend evenings to help with sleep; last use 3 days ago.
• Nicotine: Smokes 10 cigarettes daily for the past 15 years; uses nicotine vape during work hours.
• Other: Denies use of hallucinogens, inhalants, kratom, or dissociatives.

Subjective

HPI

34 YO M self-referred for MAT evaluation to stop intranasal fentanyl use. Reports escalating daily use over the past 6 months following a relapse, currently spending $300/week. Last use was 18 hours prior to arrival; currently experiencing diaphoresis, rhinorrhea, diffuse myalgias, restlessness, and GI upset. Expresses strong desire to transition to buprenorphine/naloxone to avoid losing his job and partner. Also reports worsening depressed mood, poor sleep, and low energy over the past 2 months despite taking escitalopram 10 mg daily.

Review of Systems

Constitutional: Positive for diaphoresis, chills, and fatigue; negative for fever or weight loss. HEENT: Positive for rhinorrhea and yawning. Cardiovascular: Negative for chest pain, palpitations, or edema. Respiratory: Negative for SOB, cough, or wheezing. GI: Positive for nausea and abdominal cramping; negative for vomiting or hematochezia. MSK: Positive for diffuse myalgias and chronic low back ache. Psychiatric: Positive for depressed mood, anxiety, insomnia, and opioid cravings; negative for SI, HI, or hallucinations.

Objective

Physical Exam

General: Mild distress secondary to opioid withdrawal; diaphoretic, frequent yawning, and rubbing arms. MSK: Mild resting tremor in bilateral hands and restless leg movements; no tics. Pulm: breathing effort is not increased

Mental Status Examination

APPEARANCE: well groomed, dressed casually, and consistent with stated age BEHAVIOR: Mild psychomotor restlessness (shifting in chair); eye contact and posture are appropriate. COGNITION: awake and able to sustain attention during the conversation FUND OF KNOWLEDGE: broadly average for age and education on gross examination; no formal assessment performed ATTITUDE: calm, cooperative, and communicative SPEECH: typical rate, rhythm, and volume LANGUAGE: fluent English without obvious dysarthria MOOD: "Miserable, anxious, and tired of living like this." AFFECT: Anxious, dysphoric, and congruent with stated mood; full range. THOUGHT PROCESS: organized, linear, and goal directed; no derailment, flight of ideas, or perseveration THOUGHT CONTENT: Preoccupied with physical withdrawal discomfort and cravings; no suicidal or homicidal thoughts, plans, or intent; no evident delusions, ideas of reference, or phobias. PERCEPTIONS: no obvious hallucinations or illusions INSIGHT: intact JUDGEMENT: intact