Client questionnaire - 12 month follow-up - English
Evaluation of Medication- Assisted Treatment (MAT) for Opioid Use Disorders Study
Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT
Client questionnaire - 12 month follow-up
OMB: 0920-1218
Attachment 6. Client Questionnaire, Baseline, 12 and 24 months
Form Approved
OMB No.: 0920-xxxx
Expiration Date: XX/XX/XXXX
Public Reporting burden of this collection of information varies from 40 to 60 minutes with an estimated average of 50 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).
PRIVACY ACT Section 7(a)(1)(b). The primary purpose for requesting the SSN is to assist with locating you and confirming your status if we are unable to contact you at contact information you provided. We will use your SSN to search vital records databases. You do not have to provide the requested information. Your response is voluntary. This collection is authorized under Section 301 of the Public Health Service Act (42 U.S.C. 241) 280-1a and covered by System of Records Notice (SORN) is 09-20-0136, “Epidemiologic Studies and Surveillance of Disease Problems”.
Note: The Client Questionnaire is administered at three points: baseline (initiation of new treatment episode), 12 months later, and 24 months later. It is self-administered by clients on a laptop. FI is present at baseline administration but may or may not be present at 12 and 24-month administration. Questions are meant to learn more about client’s experience of OUD treatment, demographics, quit attempts, use of MATs and counseling, economic measures, ED and hospital usage, employment, health insurance, housing, drug use (prescribed and illicit), overdoses, physical and mental health issues, criminal activity, and childhood experience of trauma. The questionnaire must be self-explanatory as it is self-administered by client with or without FI present.
Programmer Note: At the beginning of the web questionnaire, we will briefly describe the nature of the questions to be asked and include contact information for the National Suicide Prevention Lifeline, which is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. The telephone number is 1-800-273-TALK.
The Flesh-Kincaid grade reading level is 5.3.
CO1. Do you acknowledge that you have read, understand, and agree to provide your consent to participate in this survey questionnaire?
☐ Yes, I consent
☐ No, I do not consent
Programmer Note: Include a link to the full text of the informed consent. Label the link:
CO2 Click here if you wish to review the informed consent document.
CO3 Please enter your Social Security Number: [Interviewer allows respondent to enter SSN privately]
_ _ _ - _ _ - _ _ _ _
Programmer Note: If CO1=No, display the message:
CO4 You have indicated that you do not give your consent to participate in this study. If that is correct, confirm that you have withdrawn consent. A member of our research team will contact you to discuss your concerns. Be assured, you always have the right to not answer any question and to withdraw consent any time. If this is not correct, confirm that you do provide consent below and you will be taken to the next question.
☐ Yes, I consent [Return client to CO1]
☐ No, I do not consent [Go to END]
Programmer Note: MAT/COUN = type of treatment client is receiving at index facility. Codes are MMT, BUP, NTX, and COUN.
If MMT, use “methadone maintenance therapy”
If BUP, use “buprenorphine (e.g. Suboxone, Probuphine, generic)”
If NTX, use “naltrexone (e.g. Vivitrol, Revia, generic)”
If COUN, use “counseling”
FACILITY = the Short_Name of the index facility
START=the date that index treatment began
INDEX DAYS=days spent in INDEX treatment. If still in INDEX treatment, INDEX DAYS = (today-START). If no longer in INDEX treatment, INDEX DAYS=(date ended treatment (SS3) – START)
Define
Index Treatment
BASE: All not previously sent to END.
SS1. You were invited to be in the MAT Study because you were treated for opioid addiction at (FACILITY) using (MAT/COUN) starting (START).
This is your INDEX treatment.
☐ Click here if you did not receive the INDEX treatment described above.
Programmer Note: If ☐ is clicked, display message below and go to END.
There appears to be an error in our records. Please accept our apologies. A member of the research staff will be in contact with you to resolve the error.
Survey Manager Note: Reconcile error and refield the survey.
Dates of Index Treatment
BASE: All not previously sent to END
SS2. Are you still receiving your INDEX treatment?
Answer NO if:
you stopped going to (FACILITY)
you stopped receiving (MAT/COUN)
you started receiving (MAT/COUN) at a different facility
you still go to (FACILITY) but started receiving a different type of treatment for opioid addiction
☐ Yes
☐ No
BASE: SS2=No
SS3. When did you stop receiving your INDEX treatment? (Enter an approximate date if you are unsure of the exact date.)
_____/_____/_____
Month / Day / Year
Reason to Stop INDEX Treatment
BASE: SS2=No
Programmer note: Do NOT randomly order list.
SS4. Why did you stop receiving your INDEX treatment? (If you have multiple reasons, select the most important reason.)
☐ I completed my INDEX treatment
☐ I voluntarily stopped my INDEX treatment
☐ I continued my [MAT/COUN] treatment at a different facility
☐ I am still receiving treatment for my opioid addiction at (FACILITY), but I am no longer receiving [MAT/COUN]
☐ I was involuntarily discharged from my INDEX treatment program (e.g., for non-compliance, for continued substance use, for violating program rules, for non-payment, etc.)
☐ A different reason/none of the above (specify): _______________
BASE: SS2=No
Programmer note: Randomly order list except none category. 1=checked, 0=not checked
SS5. Here are reasons someone might stop treatment. Did any of these apply to your situation? (Check all that apply.)
The program took up too much of my time
I couldn’t find or afford daycare for my kids.
My insurance ran out.
I couldn’t find a way to pay for it.
I didn’t have reliable transportation.
I got sick and couldn’t make appointments.
I didn’t think the treatment was doing any good.
I didn’t need the treatment anymore.
I didn’t like the people.
I relapsed.
I went to jail
I moved too far away
None of these apply
Characteristics of INDEX Treatment
BASE: Only administer at baseline.
Programmer note: Randomly order list
SS5a-p. How important were the following reasons for starting your INDEX treatment?
a. I believed I had to get treatment
☐ Very important
☐ Somewhat important
☐ Not important
b. My employer believed I had to get treatment
c. My friends/family believed I had to get treatment
d. I failed at getting off drugs on my own
e. I found the type of treatment I wanted
f. There was an opening in the facility I wanted
g. I had transportation I needed
h. I had childcare I needed
i. Treatment was close enough to me
j. Treatment was covered under my health care plan
k. I could afford it
l. I decided I couldn’t handle my addiction on my own
m. I overdosed and was frightened for my life
n. I hit rock bottom
o. I could not find heroin or prescription opioids and was experiencing withdrawal symptoms
p. My doctor recommended that I get treatment
BASE: Only administer at baseline.
Programmer note: Do NOT randomly order list. Checked=1, not checked=0.
SS6a-h. Was your participation in the INDEX treatment… (Check any that apply):
☐ a. To comply with a court-order
☐ b. To avoid a conviction on a charge(s)
☐ c. To meet a condition of your probation or parole
☐ d. To avoid going to jail or prison
☐ e. To avoid being charged with misdemeanor
☐ f. To avoid being charged with a felony
☐ g. To get your driver’s license back
☐ h. To reduce the points against your license
☐ i. To comply with a child welfare order
☐ j. To help retain or gain custody of children
☐ k. None of these apply
BASE: Only administer at baseline.
Programmer note: Do NOT randomly order list. Checked=1, not checked=0.
SS7a-h. Who recommended that you go to (FACILITY) to get your INDEX treatment? (Check all that apply.)
☐ a. I picked it myself
☐ b. Friends or family members
☐ c. Alcohol/ drug abuse care provider
☐ d. Primary health care provider
☐ e. School-based counselor
☐ f. Employer
☐ g. Community group (e.g. religious organizations or self-help groups)
☐ h. Court/criminal justice referral (e.g. police official, judge, prosecutor, probation officer)
☐ i. None of these apply
BASE: Only administer at baseline.
Programmer note: Do NOT randomly order list.
SS8. How would you best describe the place you received your INDEX treatment?
☐ Methadone center/treatment facility
☐ Drug rehabilitation center/treatment facility
☐ Mental health center/treatment facility
☐ Specialty addiction doctor
☐ General doctor's office or primary care physician
☐ Office-based counseling with psychiatrist, psychologist, or social worker
☐ Other type of place
BASE: Only administer at baseline.
Programmer note: Do NOT randomly order list.
SS9. This treatment was:
☐ Inpatient
☐ Residential
☐ Intensive outpatient
☐ Outpatient
☐ Other
BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).
Programmer note: Do NOT randomly order list. Checked=1, not checked=0.
SS10. While enrolled in INDEX treatment, did you receive: (Check all that apply.)
☐ Methadone
☐ Oral buprenorphine (e.g., Suboxone®, generic)
☐ Implantable and injectable buprenorphine (e.g., Probuphine®, generic)
☐ Oral naltrexone (e.g., Revia®)
☐ Injectable naltrexone (e.g., Vivitrol®)
☐ Other drug (specify) _____________________________
☐ No drug
BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).
Programmer note: Randomly order list (except Other Services and No Other Services). Checked=1, not checked=0.
SS11a-n. While enrolled in INDEX treatment, what other types of services did you receive: (Check all that apply.)
☐ a. Individual counseling
☐ b. Group counseling
☐ c. Other behavioral therapy/counseling
☐ d. Detoxification services
☐ e. Medical services (e.g., physical exams, medication)
☐ f. HIV testing
☐ g. Hepatitis C virus (HCV) testing
☐ h. Laboratory drug testing/ urine testing
☐ i. Case management services (e.g., employment coaching, family services/education, housing services)
☐ j. Peer-to-peer recovery support services (e.g., Peer Navigator)
☐ k. Recovery coach services other than Peer Navigator
☐ l. Training on how to avoid overdosing
☐ m. Training on how to use naloxone
☐ n. Other services
☐ o. No other services
Programmer Note: If “no other services” is checked or question is skipped, display:
You did not check any of the above services. Click here ☐ to go back and enter service(s) or click here ☐ to confirm you received no other services.
BASE: Only administer at baseline.
SS12. When you entered your INDEX treatment, how confident were you that your INDEX treatment would be successful?
☐ Not confident
☐ Slightly confident
☐ Moderately confident
☐ Highly confident
Peer Navigator/Provider Services (PN)
A “Peer Navigator” (also referred to as a “Peer Provider” or “Peer Support Specialist”) refers to a person who uses their personally lived experiences with addiction and recovery in a treatment setting to promote recovery and resiliency for individuals with the same or similar conditions.
BASE: Ask if R is still enrolled in INDEX treatment (SS2 = Yes) plus the first quex where R says they are no longer enrolled in INDEX treatment (first time SS2 = No).
Programmer Note: The following definition should appear here and be available as clickable definition wherever the term Peer Navigator occurs.
PN1. [SS2=YES: Since you started your INDEX treatment at (FACILITY)/
FIRST TIME SS2=NO: While you were in your INDEX treatment]
were you offered services from a peer navigator?
☐ Yes
☐ No
BASE: If PN1=Yes
PN2. [SS2=YES: Since you began your INDEX treatment,/
[FIRST TIME SS2=No: At any time while you were in your INDEX treatment]
how often did you met with a peer navigator?
☐ Less than once a month
☐ About once a month
☐ Several times a month
☐ About once a week
☐ Several times a week
☐ I never met with a peer navigator
Programmer note: If R still in INDEX treatment, use “is”. If no longer in INDEX treatment, use “was”.
BASE: If PN1=Yes
PN3. How helpful [SS2=YES:is/SS2=NO:was) your peer navigator to your recovery?
☐ Very helpful
☐ Somewhat helpful
☐ Somewhat unhelpful
☐ Not helpful at all
BASE: If PN2= “I never met with a peer navigator”
Programmer Note: Do NOT randomize list. Checked=1, unchecked=0
PN4. Why did you not meet with a peer navigator? (Check all that apply.)
☐ I did not want the service
☐ I did not think the service was worthwhile for me
☐ I could not afford the service
☐ I will arrange to meet with peer navigator if I ever need their service
☐ I tried to make an appointment but the peer navigator did not have any openings on their schedule
☐ I plan to schedule an appointment soon
☐ I have an appointment scheduled
☐ I had an appointment but the peer navigator didn’t make it
☐ I had another reason that’s not listed above (specify): _____________
BASE: If PN1=Yes or No
Programmer note: Randomize list.
PN5. Whether or not you have ever worked with a peer navigator, we’d like to know if you agree or disagree with the following statements about peer navigators.
Peer navigators are helpful
☐ Agree
☐ Neutral or no opinion
☐ Disagree
I am uncomfortable sharing my personal life with a peer navigator
People I know told me not to work with a peer navigator
A peer navigator is not helpful or needed given my situation
I would recommend peer navigators to a friend
“Abuse opioids” means that you:
used heroin,
used illicitly-made fentanyl, or
used prescription opioids non-medically
Non-medically means you
Used prescription opioids in a way other than directed by a doctor
Used prescription opioids that were not prescribed for you personally
Used any prescription opioids to get high or buzzed
Used any prescription opioids to self-treat a medical condition
OU1. When was the last time you abused opioids before entering your INDEX treatment?
☐ The same day (START)
☐ 1-2 day before
☐ 3-7 days before
☐ 8-14 days before
☐ More than 14 days before
OU2. Since (START), have you abused opioids even once?
☐ Yes
☐ No
BASE: If OU2 = Yes
OU3. [IF SS2=YES: It has been (INDEX DAYS) since you started treatment at (FACILITY)/
IF SS2=NO: You were in INDEX treatment for (INDEX DAYS)], how many of those days did you abuse opioids?
☐ Days (specify) _______
☐ None
OU4. [12-MONTH: You started your INDEX treatment about 12 months ago. Since then, how often have you abused opioids? /
24-MONTH: In the last 12 months, how often have you abused opioids?]
☐ I have not abused any opioids since beginning my INDEX treatment
☐ I have abused opioids a couple times but have not gone back to using opioids regularly
☐ I have abused opioids for several of the past 12 months
☐ I have abused opioids for most or all of the past 12 months
BASE: If SS2=No
PX1. Since stopping your INDEX treatment, did you start another treatment program for opioid addiction?
Answer YES if:
you started receiving (MAT/COUN) at a different facility
you still go to (FACILITY) but started receiving a different type of treatment for opioid addiction
☐ Yes
☐ No ► GO TO MODULE V. PRE-INDEX TREATMENT HISTORY
BASE: PX1=Yes
PX2. When did you begin receiving this treatment? (Enter an approximate date if you are unsure of the exact date.)
_____/_____/_____
MM / DD / YY
BASE: PX1=Yes
Programmer note: Randomly order list.
PX3a-p. How important were the following reasons for starting this treatment:
a. I believed I needed treatment
☐ Very important
☐ Somewhat important
☐ Not important
b. My employer believed I had to get treatment
c. My friends/family believed I had to get treatment
d. I failed at getting off drugs on my own
e. I found the type of treatment I wanted
f. There was an opening in the facility I wanted
g. I had transportation I needed
h. I had childcare I needed
i. Treatment was close enough to me
j. Treatment was covered under my health care plan
k. I could afford it
l. I decided I couldn’t handle my addiction on my own
m. I overdosed and was frightened for my life
n. I hit rock bottom
o. I could not find heroin or prescription opioids and was experiencing withdrawal symptoms
p. My doctor recommended that I get treatment
BASE: PX1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PX4a-h. Was your participation in this treatment (Check any that apply):
☐ To comply with a court-order
☐ To avoid a conviction on a charge(s)
☐ To meet a condition of your probation or parole
☐ To avoid going to jail or prison
☐ To avoid being charged with misdemeanor
☐ To avoid being charged with a felony
☐ To get your driver’s license back
☐ To reduce the points against your license
☐ To comply with a child welfare order
☐ To help retain or gain custody of children
☐ None of these apply
BASE: PX1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PX5a-h. Who recommended that you go to this facility to get treatment? (Check all that apply.)
☐ a. I picked it myself
☐ b. Friends or family members
☐ c. Alcohol/ drug abuse care provider
☐ d. Primary health care provider
☐ e. School-based counselor
☐ f. Employer
☐ g. Community group (e.g. religious organizations. self-help groups)
☐ h. Court/ criminal justice referral (e.g. police official, judge, prosecutor, probation officer)
☐ i. None of these apply
BASE: PX1=Yes
Programmer note: Do NOT randomly order list
PX6. How would you best describe the place you received this treatment?
☐ Drug rehabilitation center/service
☐ Mental health center or facility
☐ Specialty addiction doctor
☐ General doctor's office or primary care physician
☐ Office-based counseling with psychiatrist, psychologist, or social worker
☐ Other type of place
BASE: PX1=Yes
Programmer note: Do NOT randomly order list.
PX7. This treatment was:
☐ Inpatient
☐ Residential
☐ Intensive outpatient
☐ Outpatient
☐ Other
BASE: PX1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked = 0
PX8. While enrolled in this treatment, did you receive: (Check all that apply.)
☐ Methadone
☐ Oral buprenorphine (e.g. Suboxone®, generic)
☐ Implantable or injectable buprenorphine (e.g. Probuphine®, generic)
☐ Oral naltrexone (e.g. Revia®)
☐ Injectable naltrexone (e.g. Vivitrol®)
☐ Other drug (specify) _____________________________
☐ No drug
BASE: PX1=Yes
Programmer note: Randomly order list (except Other and No Other Services). Checked=1, not checked=0. Split between 2 or 3 screens.
PX9a-n. While enrolled in this treatment, what other types of services did you receive: (Check all that apply.)
☐ a. Individual counseling
☐ b. Group counseling
☐ c. Other behavioral therapy
☐ d. Detoxification services
☐ e. Medical services (e.g., physical exams, medication)
☐ f. HIV testing
☐ g. Hepatitis C virus (HCV) testing
☐ h. Laboratory drug testing/ urine testing
☐ i. Case management services (e.g., employment coaching, family services/education, housing services)
☐ j. Peer-to-peer recovery support services (e.g., Peer Navigator)
☐ k. Recovery coach services other than Peer Navigator
☐ l. Training on how to avoid overdosing
☐ m. Training on how to use naloxone
☐ n. Other services
☐ o. No other services
Programmer Note: If “No other services” is checked or question is skipped, display: You did not check any of the above services. Click here ☐ to go back and enter service(s) or click here ☐ to confirm you received no other services.
BASE: PX1=Yes
PX10. When you started this treatment, how confident were you that this treatment would be successful?
☐ Not confident
☐ Slightly confident
☐ Moderately confident
☐ Highly confident
BASE: PX1=Yes
PX11. Are you still receiving this treatment at this facility?
☐ Yes
☐ No
BASE: If PX11 = No
PX12. When did you stop receiving treatment at this facility?
MM/DD/YY
BASE: If PX11 = No
Programmer note: DO NOT randomly order list.
PX13. Why did you stop receiving this treatment at this facility?
☐ I completed this treatment program
☐ I voluntarily stopped this treatment
☐ I continued this treatment at a different facility
☐ I am still receiving treatment for my opioid addiction at this facility but I changed treatments
☐ I was involuntarily discharged from this program (e.g., for non-compliance, for continued substance use, for violating program rules, for non-payment, etc.)
☐ A different reason/none of the above (specify): __________
BASE: If PX11 = No
Programmer note: Randomly order list except none category. 1=checked, 0=not checked
PX14. Here are reasons someone might stop treatment. Did any of these apply to your situation? (Check all that apply.)
Programmer note: Use response categories to SS5
BASE: If PX11 = No
PX14. Did you enter treatment for opioid addiction anywhere else after that?
☐ Yes
☐ No
Programmer note: Repeat PX series until R either says they are still obtaining treatment (PX11=Yes) or they say that they have not entered another treatment (PX15=No)
Programmer Note: The PH sequence covers the 12 months before INDEX. It will only be administered at Baseline.
BASE: All at baseline
PH1. In the 12 months before you started your INDEX treatment, did you receive any treatment for opioid addiction?
☐ Yes
☐ No ► GO TO VI. QUIT ATTEMPTS MODULE
BASE: PH1=Yes
PH2. Were you in any type of treatment for opioid addiction 12 months ago, that is, around this time last year?
☐ Yes
☐ No
If PH2=No
PH3. When did you first start treatment in the last 12 months?
_____/_____/_____
MM / DD / YY
BASE: PH1=Yes
Programmer note: Randomly order list. Checked=1, not checked =0.
PH4a-p. How important were the following reasons for starting this treatment?
a. I believed I needed treatment
☐ Very important
☐ Somewhat important
☐ Not important
b. My employer believed I had to get treatment
c. My friends/family believed I had to get treatment
d. I failed at getting off drugs on my own
e. I found the type of treatment I wanted
f. There was an opening in the facility I wanted
g. I had transportation I needed
h. I had childcare I needed
i. Treatment was close enough to me
j. Treatment was covered under my health care plan
k. I could afford it
l. I decided I couldn’t handle my addiction on my own
m. I overdosed and was frightened for my life
n. I hit rock bottom
o. I could not find heroin or prescription opioids and was experiencing withdrawal symptoms
p. My doctor recommended that I get treatment
BASE: PH1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PH5a-h. Was your participation in this treatment (Check any that apply):
☐ a. To comply with a court-order
☐ b. To avoid a conviction on a charge(s)
☐ c. To meet a condition of your probation or parole
☐ d. To avoid going to jail or prison
☐ e. To avoid being charged with misdemeanor
☐ f. To avoid being charged with a felony
☐ g. To get your driver’s license back
☐ h. To reduce the points against your license
☐ i. To comply with a child welfare order
☐ j. To help retain or gain custody of children
☐ k. None of these apply
BASE: PH1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PH6a-h. Who recommended that you go to this facility to get treatment? (Check all that apply.)
☐ a. I picked it myself
☐ b. Friends or family members
☐ c. Alcohol/ drug abuse care provider
☐ d. Other health care provider
☐ e. School-based counselor
☐ f. Employer
☐ g. Other community referral (e.g. religious organizations or self-help groups)
☐ h. Court/ criminal justice referral (e.g. police official, judge, prosecutor, probation officer)
☐ i. None of these apply
BASE: PH1=Yes
Programmer note: Do NOT randomly order list.
PH7. How would you best describe the place you received this treatment?
☐ Drug rehabilitation center/service
☐ Mental health center or facility
☐ Specialty addiction doctor
☐ General doctor's office or primary care physician
☐ Office-based counseling with psychiatrist, psychologist, or social worker
☐ Other type of place
BASE: PH1=Yes
PH8. When you entered this treatment, how confident were you that this treatment would be successful?
☐ Not confident
☐ Slightly confident
☐ Moderately confident
☐ Highly confident
BASE: PH1=Yes
Programmer note: Do NOT randomly order list.
PH9. This treatment was:
☐ Inpatient
☐ Residential
☐ Intensive outpatient
☐ Outpatient
☐ Other (specify): ______________
BASE: PH1=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PH10. While enrolled in this treatment, did you receive: (Check all that apply.)
☐ Methadone
☐ Oral buprenorphine (e.g. Suboxone®, generic)
☐ Implantable or injectable buprenorphine (e.g. Probuphine®, generic)
☐ Oral naltrexone (e.g. Revia®)
☐ Injectable naltrexone (e.g. Vivitrol®)
☐ Other drug (specify) _____________________________
☐ No drug
BASE: PH1=Yes
Programmer note: Randomly order list (except Other). Checked=1, not checked=0
PH11a-n. While enrolled in this treatment, what other types of services did you receive: (Check all that apply.)
☐ Individual counseling
☐ Group counseling
☐ Other behavioral therapy
☐ Detoxification services
☐ Medical services (e.g., physical exams, medication)
☐ HIV testing
☐ Hepatitis C virus (HCV) testing
☐ Laboratory drug testing/ urine testing
☐ Case management services (e.g., employment coaching, family services/education, housing services)
☐ Peer-to-peer recovery support services (e.g., Peer Navigator)
☐ Recovery coach services other than Peer Navigator
☐ Training on how to avoid overdosing
☐ Training on how to use naloxone
☐ Other services (specify): _____________
Programmer Note: If no services are checked, display: You did not check any of the above services. Click here ☐ to go back and enter service(s) or click here ☐ to confirm you received no other services.
BASE: PH1=Yes
PH12. When did you stop receiving treatment at this facility?
_____/_____/_____
MM / DD / YY
BASE: PH1=Yes
Programmer note: Do NOT randomly order list.
PH13. Why did you stop obtaining treatment there?
☐ I completed my treatment program
☐ I decided to stop receiving treatment
☐ I continued my treatment at a different facility
☐ I am still receiving treatment for my opioid addiction at this facility but I changed treatments
☐ I was involuntarily discharged from this program (e.g., for non-compliance, for continued substance use, for violating program rules, for non-payment, etc.)
☐ A different reason/none of the above (specify): ___________________
BASE: PH1=Yes
PH14. Did you enter treatment anywhere else after that?
☐ The next treatment I received was my INDEX treatment
☐ I started treatment for my opioid addiction somewhere else
Programmer note: Repeat PH series until R says they entered index treatment (PH14=1)
[BASELINE: Think about the 12 months prior to
starting treatment at (FACILITY)/
12MONTH: Think about the 12
months since you started treatment at (FACILITY)/
24MONTH: Think
about the last 12 months]
BASE: All clients not previously sent to END
QA1. How many times did you try to quit opioids voluntarily (and not simply because you could not obtain opioids)? [If 12MONTH: Include the time you received treatment at (facility)].
Times (0-99, soft check)
None (Zero)
BASE: QA1>0
QA2. Of these [insert QA1] times, how many times did you quit opioids for more than five days?
______ Times
Programmer note: 0-QA1, soft check
BASE: QA1>0
QA3. Of these [insert QA1] times, what was the longest time you quit opioids?
☐ Less than one day
☐ 1 to 2 days
☐ 3 to 7 days
☐ 8 to 14 days
☐ 2 to 4 weeks
☐ 1 to 3 months
☐ 4 to 6 months
☐ More than 6 months
The following questions ask about medications you have been prescribed by healthcare providers to treat opioid addiction.
Methadone
(MM)
Methadone is an oral medication taken daily to reduce withdrawal symptoms in people addicted to heroin or other prescription opioids. It must be administered by a health professional.
BASE: All not previously sent to END
MM1. Have you ever been in a methadone maintenance program to treat opioid addiction?
☐ Yes
☐ No
BASE: MM1=Yes (ever in methadone program). BASELINE ONLY.
MM3. Did you receive methadone to treat opioid addiction at any time in the 12 months before you entered your INDEX treatment?
☐ Yes
☐ No
BASE: MM3=Yes. BASELINE ONLY.
MM3.a. Did you receive methadone to treat opioid addiction at any time in the 90 days before you entered your INDEX treatment?
☐ Yes
☐ No
BASE: MM1=Yes
Programmer note: If R still in INDEX treatment (SS2=Yes), use “Do . . .”. If not longer in INDEX treatment (SS2=No), use “Did . . .”.
MM4. Did/Do you receive methadone as part of your INDEX treatment?
☐ Yes
☐ No
BASE: MM4=No
BASE: 12 MONTH
MM5. Did you receive methadone treatment for opioid addiction at any time since your INDEX treatment?
☐ Yes
☐ No
BASE: MM4=No
BASE: 24 MONTH
MM6. Did you receive methadone treatment for opioid addiction at any time in the past 12 months? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
MM6.a. Did you receive methadone treatment for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
BASE: MM1=Yes (been in methadone program)
MM7. Are you currently being treated with methadone for opioid addiction?
☐ Yes
☐ No
BASE: MM7=Yes
MM8. When did you start your current methadone treatment program?
Start: _____/_____/_____
MM / DD / YY
BASE: MM7=No (in methadone treatment in past year but not currently)
MM8- 9. When did you start and end your last treatment program using methadone?
MM8: Start: _____/_____/_____
MM / DD / YY
MM9: End: _____/_____/_____
MM / DD / YY
BASE: MM1=Yes
Thinking about your most recent methadone treatment,
MM10. (Do/did) you usually take methadone every day as directed by your doctor?
☐ Yes
☐ No
BASE: MM1=Yes
MM11. How many milligrams of methadone was the treatment dose the last time you took methadone?
__________ Milligrams
BASE: MM1=Yes
MM12. How often did you give away or sell the methadone you were prescribed?
☐ Never
☐ Rarely
☐ Sometimes
☐ Often
☐ Very often
BASE: All
MM13. In the past 12 months, how often have you used methadone that was not prescribed to you?
☐ Never
☐ Rarely
☐ Sometimes
☐ Often
☐ Very often
BASE: MM13 >1
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
MM14. What was the reason you took methadone not prescribed for you? (Check all that apply.)
☐ To get high
☐ To prevent withdrawal
☐ To self-medicate for physical pain
☐ To self-medicate for emotional pain
☐ Other reason (specify): ____________________
BASE: MM1=Yes or MM13 >1
MM15. Did you ever notice any adverse effects or unexpected symptoms after taking methadone?
☐ Yes
☐ No
BASE: MM15=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
MM16. What were some of the adverse effects or unexpected symptoms (Check all that apply.)
☐ Profuse sweating
☐ Heavy sedation
☐ Anxiety
☐ Continued having cravings to abuse opioids
☐ Feeling high or buzzed
☐ Other effects or symptoms (specify): _______________
☐ None of the above
BASE: MM1=Yes and MM7=No (been in methadone program but not now) and MM15=Yes
MM17. How strongly did these adverse effects or symptoms influence your decision to stop taking methadone to treat opioid addiction?
☐ Strongly influenced
☐ Somewhat influenced
☐ Did not influence
Oral
Buprenorphine (BU)
Oral buprenorphine is taken to help reduce withdrawal symptoms. It is sometimes combined with naloxone (for example, Suboxone)
BASE: All not previously sent to END
BU1. Have you ever received oral buprenorphine to treat opioid addiction?
☐ Yes
☐ No
BASE: BU1=Yes (ever in oral buprenorphine program)
BU3. Did you receive oral buprenorphine to treat opioid addiction any time in the 12 months before your INDEX treatment?
☐ Yes
☐ No
BU3.a. Did you receive oral buprenorphine to treat opioid addiction any time in the 90 days before your INDEX treatment?
☐ Yes
☐ No
BASE: BU1=Yes
Programmer note: If R still in INDEX treatment (SS2=Yes), use “Do . . .”. If not longer in INDEX treatment (SS2=No), use “Did . . .”.
BU4. Did/do you receive oral buprenorphine as part of your INDEX treatment?
☐ Yes
☐ No
BASE: BU4=No
BASE: 12 MONTH
BU5. Did you receive oral buprenorphine for opioid addiction at any time since your INDEX treatment?
☐ Yes
☐ No
BASE: BU4=No
BASE: 24 MONTH
BU6. Did you receive oral buprenorphine for opioid addiction at any time in the past 12 months? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
BU6.a. Did you receive oral buprenorphine for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
BASE: BU1=Yes
BU7. Are you currently being treated with oral buprenorphine for opioid addiction?
☐ Yes
☐ No
BASE: BU7=Yes
BU8. When did you start your current oral buprenorphine treatment?
Start: _____/_____/_____
MM / DD / YY
BASE: BU7=No (in oral buprenorphine treatment in past year but not currently)
BU8-9. When did you start and end your last treatment program using oral buprenorphine?
BU8:
Start: _____/_____/_____
MM / DD / YY
BU9:
End : _____/_____/_____
MM / DD / YY
BASE: BU1=Yes
Programmer note: If R still in treatment (BU7=Yes), use “Do . . .”. If not longer in treatment (BU7-=No), use “Did . . .”.
Thinking about your most recent oral buprenorphine treatment program,
BU10. (Do/did) you usually take oral buprenorphine every day as directed by your doctor?
☐ Yes
☐ No
BASE: BU1=Yes
BU11. How many milligrams of oral buprenorphine was the treatment dose the last time you took oral buprenorphine?
Milligrams
BASE: BU1=Yes
80a) BU11a. Did you receive a prescription for oral buprenorphine to take the medication at home?
☐ Yes
☐ No
BASE: BU11a=Yes
80b) BU11b. How long was the prescription for?
☐ Less than 1 week (less than 7 days)
☐ 1 week (7 days)
☐ 2 weeks (14 days)
☐ 30 days
BASE: BU1=Yes
BU12. How often did you give away or sell the oral buprenorphine you were prescribed?
☐ Never
☐ Rarely
☐ Sometimes
☐ Often
☐ Very often
BASE: All
BU13. In the past 12 months, how often have you used oral buprenorphine that was not prescribed to you?
☐ Never
☐ Rarely
☐ Sometimes
☐ Often
☐ Very often
BASE: BU13>1
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
BU14. What was the reason you took oral buprenorphine not prescribed for you? (Check all that apply.)
☐ To get high
☐ To prevent withdrawal
☐ To self-medicate for physical pain
☐ To self-medicate for emotional pain
☐ Other reason (specify): ___________
BASE: BU1=Yes or BU13>1
BU15. Did you ever notice any adverse effects or unexpected symptoms after taking oral buprenorphine?
☐ Yes
☐ No
BASE: BU15=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
BU16. What were some of the adverse effects or unexpected symptoms (Check all that apply.)
☐ Profuse sweating
☐ Heavy sedation
☐ Anxiety
☐ Continued having cravings to abuse opioids
☐ I felt high or buzzed
☐ Other effects or symptoms (specify): ____________
☐ None of the above
BASE: BU1=Yes and BU7=No (been in oral buprenorphine program but not now) and BU15=Yes (had side effects)
BU17. How strongly did these adverse effects or symptoms influence your decision to stop taking oral buprenorphine to treat opioid addiction?
☐ Strongly influenced
☐ Somewhat influenced
☐ Did not influence
Implantable or Injectable Buprenorphine (PB)
Implantable or injectable buprenorphine is administered monthly in your arm or other location on your body to help reduce withdrawal symptoms. It lasts about 30 days. It must be administered by a health professional. You may know it as Probuprine or other names.
BASE: All not previously sent to END
PB1. Have you ever received a buprenorphine implant or injection to treat opioid addiction?
☐ Yes,
☐ No
BASE: PB1=Yes (ever in implantable or injectable BUP program)
PB1type. Did you receive the implant or injection, or both?
☐ Implant
☐ Injection
☐ Both
☐ Neither
PB2. Did you receive a buprenorphine implant or injection to treat opioid addiction any time in the 12 months before your INDEX treatment?
☐ Implant
☐ Injection
☐ Both
☐ Neither
PB2.a. Did you receive a buprenorphine implant or injection to treat opioid addiction any time in the 90 days before your INDEX treatment?
☐ Implant
☐ Injection
☐ Both
☐ Neither
BASE: PB1=Yes
Programmer note: If R still in INDEX treatment (SS1=Yes), use “Do . . .”. If not longer in INDEX treatment (SS1=No, use “Did . . .”.
PB4. Did/do you receive a buprenorphine implant or injection as part of your INDEX treatment?
☐ Yes
☐ No
BASE: PB4=No
BASE: 12 MONTH
PB5. Did you receive a buprenorphine implant or injection at any time since your INDEX treatment?
☐ Implant
☐ Injection
☐ Both
☐ Neither
BASE: PB4=No
24 MONTH
PB6. Did you receive a buprenorphine implant or injection at any time in the past 12 months? (Consider treatment received at ANY facility.)
☐ Implant
☐ Injection
☐ Both
☐ Neither
PB6.a. Did you receive a buprenorphine implant or injection at any time in the past 90 days? (Consider treatment received at ANY facility.)
☐ Implant
☐ Injection
☐ Both
☐ Neither
BASE: PB1=Yes (been in a buprenorphine implant/injection program)
PB7. Are you currently receiving buprenorphine implants or injections?
☐ Yes
☐ No
BASE: PB7=Yes
PB8. When did you start your current buprenorphine implant/injection program?
Start: MM/DD/YY
BASE: PB7=No (received buprenorphine implant/injection in past year but not currently)
PB8-9. When did you start and end your last treatment program using buprenorphine implants/ injections?
PB8: Start: MM/DD/YY
PB9: End: MM/DD/YY
BASE: PB1=Yes
Thinking about the last time you received a buprenorphine implant or injection,
PB11. How many milligrams of buprenorphine was in the last implant/injection you received?
Milligrams
BASE: PB1=Yes
PB15. Did you ever notice any adverse effects or unexpected symptoms after receiving a buprenorphine implant/injection?
☐ Yes
☐ No
BASE: PB15=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PB16. What were some of the adverse effects or unexpected symptoms (Check all that apply,)
☐ Profuse sweating
☐ Heavy sedation
☐ Anxiety
☐ Continued having cravings to abuse opioids
☐ I felt high or buzzed
☐ Other effects or symptoms (specify): ____________
☐ None of the above
BASE: PB1=Yes and PB7=No (been in a buprenorphine implant/injection program but not now) and PB15=Yes (had side effects)
PB17. How strongly did these adverse effects or symptoms influence your decision to stop receiving buprenorphine implants/injections to treat opioid addiction?
☐ Strongly influenced
☐ Somewhat influenced
☐ Did not influence
Oral
Naltrexone (ON)
Oral naltrexone is a pill taken daily that blocks the effects of opioids and reducing cravings. You must detox before taking oral naltrexone. The most common brand name is Revia.
BASE: All not previously sent to END
ON1. Have you ever received oral naltrexone to treat opioid addiction?
☐ Yes
☐ No
BASE: ON1=Yes (ever in oral naltrexone program)
ON3. Did you receive oral naltrexone to treat opioid addiction any time in the 12 months before your INDEX treatment?
☐ Yes
☐ No
ON3.a. Did you receive oral naltrexone to treat opioid addiction any time in the 90 days before your INDEX treatment?
☐ Yes
☐ No
BASE: ON1=Yes
ON4. Did you receive oral naltrexone as part of your INDEX treatment?
☐ Yes
☐ No
BASE: ON4=No
BASE: 12 MONTH
ON5. Did you receive oral naltrexone for opioid addiction at any time since your INDEX treatment.
☐ Yes
☐ No
BASE: ON4=No
BASE: 24 MONTH
ON6. Did you receive oral naltrexone for opioid addiction at any time in the past 12 months? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
ON6.a. Did you receive oral naltrexone for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
BASE: ON1=Yes (been in oral naltrexone program)
ON7. Are you currently being treated with oral naltrexone for opioid addiction?
☐ Yes
☐ No
BASE: ON7=Yes
ON8. When did you start your current oral naltrexone treatment program?
Start: MM/DD/YY
BASE: ON7=No (in oral naltrexone treatment in past year but not currently)
ON8-9. When did you start and end your last treatment program using oral naltrexone?
ON8:
Start: _____/_____/_____
MM / DD / YY
ON9:
End : _____/_____/_____
MM / DD / YY
BASE: ON1=Yes
Programmer note: If R still in treatment (BU7=Yes), use “Do . . .”. If not longer in treatment (BU7-=No), use “Did . . .”.
Thinking about your most recent oral naltrexone treatment program,
ON10. (Do/did) you usually take oral naltrexone every day as directed by your doctor?
☐ Yes
☐ No
ON11. How many milligrams of oral naltrexone was the treatment dose the last time you took oral naltrexone?
Milligrams
BASE: ON1=Yes
80a) ON11a. Did you receive a prescription for oral naltrexone?
☐ Yes
☐ No
BASE: ON11a=Yes
ON11b. How long was the prescription for?
☐ Less than 1 week (less than 7 days)
☐ 1 week (7 days)
☐ 2 weeks (14 days)
☐ 30 days
BASE: ON1=Yes
ON15. Did you ever notice any adverse effects or unexpected symptoms after taking oral naltrexone?
☐ Yes
☐ No
BASE: ON15=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
BS16. What were some of the adverse effects or unexpected symptoms (Check all that apply)
☐ Profuse sweating
☐ Heavy sedation
☐ Anxiety
☐ Continued having cravings to abuse opioids
☐ I felt high or buzzed
☐ Other effects or symptoms (specify): _________
☐ None of the above
BASE: ON1=Yes and ON7=No (been in oral naltrexone program but not now) and ON15=Yes
ON17. How strongly did these adverse effects or symptoms influence your decision to stop taking oral naltrexone to treat opioid addiction?
☐ Strongly influenced
☐ Somewhat influenced
☐ Did not influence
Injectable
Naltrexone (IN)
Injectable naltrexone is an injection received monthly. It works by blocking the effects of opioids and reducing cravings. You must detox before receiving an injection of naltrexone. It must be administered by a health professional and lasts for about a month. The most common brand name is Vivitrol.
BASE: All not previously sent to END
IN1. Have you ever received injectable naltrexone to treat opioid addiction?
☐ Yes
☐ No
BASE: IN1=Yes (in injectable naltrexone program)
IN2. Did you receive naltrexone injection(s) to treat opioid addiction any time in the 12 months before your INDEX treatment?
☐ Yes
☐ No
IN2. Did you receive naltrexone injection(s) to treat opioid addiction any time in the 90 days before your INDEX treatment?
☐ Yes
☐ No
BASE: IN1=Yes
IN4. Did you receive injectable naltrexone as part of your INDEX treatment?
☐ Yes
☐ No
BASE: IN3=No
BASE: 12 MONTH
IN4. Did you receive injectable naltrexone for opioid addiction at any time since your INDEX treatment?
☐ Yes
☐ No
BASE: IN4=No
BASE: 24 MONTH
IN5. Did you receive injectable naltrexone for opioid addiction at any time in the past 12 months? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
IN6. Did you receive injectable naltrexone for opioid addiction at any time in the past 90 days? (Consider treatment received at ANY facility.)
☐ Yes
☐ No
BASE: IN1=Yes (been in injectable naltrexone program)
IN7. Are you currently receiving injectable naltrexone for opioid addiction?
☐ Yes
☐ No
BASE: IN6=Yes
IN7. When did you start your current injectable naltrexone treatment program?
Start: MM/DD/YY
BASE: IN7=No (in injectable naltrexone treatment in past year but not currently)
IN8-9. When did you start and end your last treatment program using injectable naltrexone?
IN8:
Start: _____/_____/_____
MM / DD / YY
IN9:
End : _____/_____/_____
MM / DD / YY
BASE: IN1=Yes
Programmer note: If R still in treatment (BU7=Yes), use “Do . . .”. If not longer in treatment (BU7-=No), use “Did . . .”.
BASE: IN1=Yes
IN15. Did you ever notice any adverse effects or unexpected symptoms after receiving injectable naltrexone?
☐ Yes
☐ No
BASE: IN15=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
IN16. What were some of the adverse effects or unexpected symptoms (Check all that apply)
☐ Profuse sweating
☐ Heavy sedation
☐ Anxiety
☐ Continued having cravings to abuse opioids
☐ I felt high or buzzed
☐ Other effects or symptoms (specify): ___________
☐ None of the above
BASE: IN1=Yes and IN7=No (been in injectable naltrexone program but not now) and IN15=Yes (have adverse effects)
IN17. How strongly did these adverse effects or symptoms influence your decision to stop receiving injectable naltrexone to treat opioid addiction?
☐ Strongly influenced
☐ Somewhat influenced
☐ Did not influence
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
KA1a-l. We are interested in what you think about medication-assisted treatments for opioid addiction. Answer this question whether or not you have ever taken medicine to treat opioid addiction.
Methadone
KA1a Methadone is expensive
☐ Agree Strongly
☐ Agree
☐ Disagree
☐ Strongly Disagree
KA1b Methadone is hard to get
KA1c Methadone is harder to withdraw from than opioids
KA1d Being on methadone is the same as being addicted to opioids
Buprenorphine (Suboxone)
KA1e Buprenorphine is expensive
KA1f Buprenorphine treatment is hard to get
KA1g Buprenorphine is harder to withdraw from than opioids
KA1h Being on buprenorphine is the same as being addicted to opioids
Naltrexone Injections (Vivitrol)
KA1i Naltrexone is expensive
KA1j Naltrexone is hard to get
KA1k Naltrexone is harder to withdraw from than opioids
KA1l Being on naltrexone is the same as being addicted to opioids
BASE: Only administer at Baseline and 3-month and if in MAT arm
Programmer note: Randomly order list. Checked=1, not checked=0. Break list up between 2 or 3 screens
KA2a-q. Please tell us whether each of the following occurred as part of your INDEX treatment. (Check all that apply.)
☐ We discussed how different opioid addiction treatment medications would fit with my lifestyle.
☐ I was informed about the side effects and risks of the various opioid addiction treatment medications available to me.
☐ I was asked to sign a contract acknowledging my role as a client in addiction treatment.
☐ We discussed different payment options when choosing the medication that was right for me.
☐ I was informed that I would be asked to provide urine drug screens.
☐ I was informed that I would have to return my used wrappers/foils (for buprenorphine clients).
☐ I am required to fill my prescription at a specific pharmacy.
☐ I was told that my doctor would not prescribe extra medicine if I ran out early (for buprenorphine clients).
☐ I was provided information about group counseling.
☐ We discussed target doses in relation to the size of my opioid habit
☐ We discussed the limited use of buprenorphine when opioid habits are too large
☐ We jointly developed a treatment plan for me.
☐ We discussed how long I wish to remain on this medication.
☐ I was given information about the risks associated with taking depressants (i.e., benzodiazepines and alcohol) while in treatment.
☐ I was asked about my mental health using a paper form or interview.
☐ I had a say in deciding what type of medication I would be receive
☐ We discussed the use of naloxone for overdose prevention
☐ None of these apply
Substance Abuse Treatment (SA)
BASE: 12 MONTH and 24 MONTH
BASE: All clients not previously sent to END
SA1. During the past 12 months, how many months did you receive your INDEX treatment? (Enter a number from 1 to 12. If less than one month, enter 1.)
Month(s)
BASE: SA1>0
BASE: 12 MONTH and 24 MONTH
Thinking about those (SA1) months you spent in your INDEX treatment...
SA2. How many days per month did you typically spend receiving treatment at (FACILITY)? (Consider all types of treatment received.)
☐ Days per month (specify) _______
☐ None
BASE: SA1>0
SA3. Of those days, how many days included counseling sessions (either individual or group)?
☐ Days per month (specify) _______
☐ None
BASE: SA1>0
SA4. How much time (hours, minutes) did you typically spend traveling to and from (FACILITY)? (Add up both ways.)
___________ Hours
___________ Minutes
BASE: SA1>0
SA5. How much time (hours, minutes) per visit did you typically spend at (FACILITY)? (Count the time from when you walked in to when you walked out.)
___________ Hours
___________ Minutes
BASE: SA1>0
SA6. How much time (hours, minutes) per visit did you typically miss from work to go to (FACILITY)?
___________ Hours
___________ Minutes
BASE: SA1>0
SA7. How many dollars did you typically spend traveling to get there? (Add up costs for both ways. Include gas costs, bus fees, etc.)
___________ Dollars
BASE: SA1>0
SA8. How many dollars were you typically charged for fees and copayments for a treatment visit?
___________ Dollars
SA9. Over the past 90 days, how many days did you spend receiving your INDEX treatment at (FACILITY)? (Consider all types of treatment received directly at (FACILITY).)
☐ Days (specify) _______
☐ None
SA10. Of those days, how many days did you spend in counseling sessions (either individual or group) at (FACILITY)?
☐ Days (specify) _______
☐ None
Alternative Care (AC)
BASE: Baseline, 12mo, and 24mo
Programmer note: Randomly order list a-j. Checked=1, not checked=0.
AC1. During the past 12 months, have you received treatment from any of the following health professionals: (Check all that apply.)
☐ Acupuncturist
☐ Herbalist
☐ Homeopath
☐ Hypnotist
☐ Naturopath
☐ Massage Therapist
☐ Religious Practitioner
☐ Yoga Practitioner
☐ Physical therapist
☐ Exercise coach
☐ Other
☐ None of the above
BASE: Baseline, 12mo, and 24mo. If item checked in AC1.
Programmer Note: Offer AT2, AT3 and AT4 for each provider checked in AT1 after R completes AT1. Checked=1, not checked=0.
AC2. Why did you see a (AC1)? (Check all that apply.)
☐ To help relieve pain
☐ To help with my recovery from opioids addiction
☐ To improve my general health
☐ Other reason (specify): ______
AC3. How effective was this treatment?
☐ Very effective
☐ Somewhat effective
☐ Not very effective
AC4. Did your health insurance help cover the cost of (AC1)?
☐ Yes
☐ No
☐ I don’t know
☐ I don’t have health insurance
Opioid Detoxification (DW)
Detoxification/withdrawal services are short-term, medically-supervised process addicted persons go through before they embark on a longer-term drug rehab plan. Detox is the process of getting the opioids out of the addicted person's system and getting him or her physically stable.
BASE: BASELINE
DW1. In the 12 months before you entered your INDEX treatment, how many times did you go through medically supervised opioid detox?
☐ Times (specify) _______
☐ None
BASE: Ask at BASELINE when DW1>0
DW2. In the 90 days before you entered your INDEX treatment, how many times did you go through medically supervised opioid detox?
☐ Times (specify) _______
☐ None
BASE: Ask at BASELINE
DW3. Were you required to go through medically supervised opioid detox immediately prior to entering your INDEX treatment?
☐ Yes
☐ No
BASE: Ask at 12, and 24 months
DW4. Over the past 12 months, how many times did you go through medically supervised opioid detox?
☐ Times (specify) _______
☐ None
BASE: Ask at 3, 6, 12, 24 months. If DW4>0.
DW5. Over the past 90 days, how many times did you go through medically supervised opioid detox?
☐ Times (specify) _______
☐ None
Hospital Visits (HS)
BASE: BASELINE
DO NOT INCLUDE HOSPITAL STAYS FOR DETOXING THAT YOU REPORTED ABOVE
HS1. In the 12 months before you entered your INDEX treatment, how many nights did you spend in a hospital?
☐ Nights (specify) _______
☐ None
BASE: If HS1>0
HS1a. How many of those nights were related to injuries or conditions resulting from opioid addiction?
☐ Nights (specify) _______
☐ None
BASE: BASELINE
BASE: IF HS1>0
HS2. In the 90 days before you entered your INDEX treatment, how many nights did you spend in a hospital?
☐ Nights (specify) _______
☐ None
BASE: If HS2>0
HS2a. How many of those nights were related to injuries or conditions resulting from opioid addiction?
☐ Nights (specify) _______
☐ None
BASE: Ask at 12, and 24 months
HS3. Over the past 12 months, how many nights did you spend in a hospital?
☐ Nights (specify) _______
☐ None
BASE: If HS3>0
HS3a. How many of those nights were related to injuries or conditions resulting from opioid addiction?
☐ Nights (specify) _______
☐ None
BASE: Ask at 3, 6, 12, 24 months. If HS3>0
HS4. Over the past 90 days, how many nights did you spend in a hospital?
☐ Nights (specify) _______
☐ None
BASE: If HS4>0
HO4a. How many of those nights were related to injuries or conditions resulting from opioid addiction?
☐ Nights (specify) _______
☐ None
Emergency
Department Visits (ED)
BASE: BASELINE
ED1. In the 12 months before you entered your INDEX treatment, how many times did you go to the Emergency Department?
☐ Times (specify) _______
☐ None
BASE: If ED1>0
ED1a. How many of those times were related to injuries or conditions resulting from opioid addiction?
☐ Times (specify) _______
☐ None
BASE: BASELINE
BASE: if ED1>0
ED2. In the 90 days before you entered your INDEX treatment, how many times did you go to the Emergency Department?
☐ Times (specify) _______
☐ None
BASE: If ED2>0
ED2a. How many of those times were related to injuries or conditions resulting from opioid addiction?
☐ Times (specify) _______
☐ None
BASE: Ask all at 12 and 24 months
ED3. Over the past 12 months, how many times did you go to the Emergency Department?
☐ Times (specify) _______
☐ None
BASE: If ED3>0
ED3a. How many of those times were related to injuries or conditions resulting from opioid addiction?
☐ Times (specify) _______
☐ None
BASE: Ask all at 3, 6, 12, and 24 months. If ED3>0
ED4. Over the past 90 days, how many times did you go to the Emergency Department?
☐ Times (specify) _______
☐ None
BASE: If ED4>0
ED4a. How many of those times were related to injuries or conditions resulting from opioid addiction?
☐ Times (specify) _______
☐ None
Self-Help Groups (SH)
BASE: All clients not previously sent to END
SH1. Have you ever attended a self-help group, like Alcoholics or Narcotics Anonymous?
☐ Yes
☐ No
BASE:BASELINE
BASE: SH1=Yes
SH2. In the 12 months before you entered your INDEX treatment, how many times did attend a self-help group, like Alcoholics or Narcotics Anonymous?
☐ Never
☐ Less than once a month
☐ More than once a month
☐ Most weeks
BASE: BASELINE
BASE: SH1=Yes
SH3. In the 90 days before you entered your INDEX treatment, how many times did attend a self-help group, like Alcoholics/Narcotics Anonymous?
☐ Never
☐ Less than once a month
☐ More than once a month
☐ Most weeks
BASE: 3, 6, 12, 24 MONTHS
BASE: SH1=Yes
SH5. Over the past 90 days, how many times did you attend a self-help group, like Alcoholics or Narcotics Anonymous?
☐ Never
☐ Less than once a week
☐ Once a week
☐ More than once a week
☐ Every day or almost every day of the week
BASE:12 and 24 MONTHS
BASE: SH1=Yes
SH6. Over the past 12 months, how many times did you attend a self-help group, like Alcoholics or Narcotics Anonymous?
☐ Never
☐ Less than once a week
☐ Once a week
☐ More than once a week
☐ Every day or almost every day of the week
Primary
Care Services (PC)
BASE: BASELINE
PC1. In the 12 months before you entered your INDEX treatment, how many times did you visit a primary care provider (e.g. family doctor, internists, gynecologists, physician assistant or a nurse practitioner)?
Times___________
BASE: If PC1>0
PC1a. How many of those times were related to injuries or conditions resulting from opioid addiction?
BASE: BASELINE
BASE: PC1>0
PC2. In the 90 days before you entered your INDEX treatment, how many times did you visit a primary care provider (e.g. family doctor, internists, gynecologists, physician assistant or a nurse practitioner)?
BASE: If PC2>0
PC2a. How many of those times were related to injuries or conditions resulting from opioid addiction?
BASE: 12, 24 months
PC3. Over the past 90 days, how many times did you visit a primary care provider (e.g. family doctor, internists, gynecologists, physician assistant or a nurse practitioner)?
BASE: If PC3>0
PC3a. How many of those times were related to injuries or conditions resulting from opioid addiction?
BASE: Ask at 12 and 24 months
PC4. Over the past 12 months, how many times did you visit a primary care provider (e.g. family doctor, internists, gynecologists, physician assistant or a nurse practitioner)?
BASE: If PC4>0
PC4a. How many of those times were related to injuries or conditions resulting from opioid addiction?
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
LM1. Which best describes your current work situation?
☐ Employed/Self-employed
☐ Unemployed and looking for work
☐ Unemployed and not looking for work
☐ Full-time homemaker
☐ In school or training program
☐ Retired
☐ Disabled, unable to work
☐ Other
BASE: LM1>2
LM1a. Were you employed at any point in the past 12 months?
☐ Yes
☐ No SKIP TO XI SUBSTANCE ABUSE HISTORY MODULE
BASE: LM1=Employed/Self-employed or LM1a=Yes
[LM1=1: If you currently have more than one job, answer the following questions for the job where you spend the most time. This is your primary job.]
LM1a=1: Answer the following questions for the job where you spent the most hours per week in the past 12 months. This is your primary job.
LM2. How long have/were you been employed at your primary job?
Years/months/weeks/days
LM3.
What is/was your wage, salary, or rate of pay at your primary
job, before taxes and deductions?
______
Dollars per
☐ Hour
☐ Day
☐ Week
☐ Month
☐ Other (specify) ______
LM4. How many weeks in total did you work at your primary job during the past 12 months? (Include weeks spent on paid leave such as vacation or paid maternity leave. Enter a number from 0 to 52.)
_____________ Total Weeks
LM5. How many hours per week did you usually work at your primary job during the past 12 months?
_____________ Hours per week
LM6. How many days were you absent from work at your primary job during the past 90 days? (Enter a number from 1 to 90.)
☐ Days (specify) _______
☐ None
BASE: LM6>0
LM7. Of the (LM6) days you were absent, how many were related to opioid addiction?
☐ Days (specify) _______
☐ None
LM8. In the past 12 months, did you receive money from… (Check all that apply.)
-
☐ Wages/Salary
☐ Public assistance
☐ Retirement
☐ Disability
☐ Non-legal income
☐ Family and/or friends
☐ Other (Specify) ____________________
☐ I did not receive money
These next questions are about:
street drugs you used illicitly
prescription drugs that you used non-medically
alcohol and tobacco use
Non-medically means
Used your prescribed drugs in a way other than directed by a doctor
Used prescription drugs that were not prescribed for you personally
Used any prescription drug to get high or buzzed
Used any prescription drug to self-treat a medical condition
BASE: BASELINE ONLY
Programmer note: Do NOT randomly order any lists in this section. Checked = 1, not checked=0.
SU10a-o. In your lifetime, which of the following drugs have you ever used? Be thorough. (Check all that apply.)
a) Prescription opioids used non-medically (e.g., OxyContin, Percocet, Dilaudid, Opana, Vicodin, Duragesic, Ultram, Morphine, Tramadol)
b) Prescription opioid treatment medications used non-medically (e.g., Methadone, Suboxone)
c) Prescription stimulants used non-medically (e.g., Ritalin, Adderall)
d) Prescription sedatives used non-medically (e.g., Xanax, Klonopin, Ativan)
e) Heroin
f) Illicitly-made fentanyl (not the prescription Duragesic patches)
g) Neuropathics used non-medically (e.g., gabapentin, pregabalin)
h) Marijuana/ Cannabis
i) Cocaine/Crack (e.g., powder, rock, or in any form/combination)
j) Methamphetamine/crank
k) Krokodil
l) Ecstasy, PCPs, or other synthetics
m) Inhalants
n) Alcohol
o) Tobacco
Programmer Note: For fill-in, use the following short names:
a) Prescription opioids
b) Methadone/Suboxone
c) Prescription stimulants
d) Prescription sedatives
e) Heroin
f) Illicitly-made fentanyl
g) Gabapentin
h) Marijuana/Cannabis
i) Cocaine/Crack
j) Methamphetamine/crank
k) Krokodil
l) Ecstasy, PCPs, or other synthetics
m) Inhalants
n) Alcohol
o) Tobacco
Programmer note: For SU11, ask for drugs checked in SU10. Ask SU11 immediately after subject checks drug in SU10. Do not ask for m, n, and o (inhalants, alcohol, and tobacco). Checked=1, not checked=0.
If R selects a (prescription opioids), go thru SU module, then administer PO module. Then return here to pick up next drug checked.
If R selects e (heroin), go thru go thru SU module, then administer HU module. Then return here to pick up next drug checked.
SU11a-l. In your lifetime, in what ways have you used (SU10)? (Check all that apply.)
☐ Oral, swallowed intact (e.g., whole pill)
☐ Oral, swallowed after chewing/crushing
☐ Oral, ate with food (e.g., marijuana brownies)
☐ Smoked
☐ Snorted
☐ Injected
☐ None of these apply
Programmer note: For SU20, only ask about drugs reported in SU10.
SU20a-o. In the 12 months before you entered your INDEX treatment, how often did you use (SU10) :
☐ Never
☐ Less than once a month
☐ About once a month
☐ More than once a month
☐ Most weeks
Programmer note: For SU21, only ask for drugs checked in SU20 > Never. Ask SU21 immediately after subject checks drug in SU20. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU21a-l. In the 12 months before you entered your INDEX treatment, in what ways have you used (SU20)? (Check all that apply.)
Programmer note: Use SU11 response categories.
Programmer note: For SU30, only ask about drugs reported in SU20 (>Never). If none, skip this item.
SU30a-o. In the 90 days before you entered your INDEX treatment, how often did you use (SU20):
☐ Never
☐ Less than once a week
☐ Once a week
☐ More than once a week
☐ Almost every day of the week
Programmer note: For SU31, only ask for drugs checked in SU30 >Never. Ask SU31 immediately after subject selects drug in SU30. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU31a-l. In the 90 days before you entered your INDEX treatment, in what ways have you used (SU30)? (Check all that apply.)
Programmer note: Use SU11 response categories.
Programmer note: For SU40, only ask about drugs reported in SU30 >Never. If none, skip this item.
SU40a-o. In the 30 days before you entered your INDEX treatment, how many days did you use (SU30)?
☐ Days (specify 1-30) _______
☐ None
Programmer note: For SU41, only ask for drugs reported in SU40>0. Ask SU41 immediately after subject selects drug in SU40. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU41a-l. In the 30 days before you entered your INDEX treatment, in what ways have you used (SU40)? (Check all that apply.)
Programmer note: Use SU11 response categories.
BASE: 12 and 24 MONTHS
SU50a-o. Over the past 12 months, how often did you use the following drugs?
Programmer note: Use list from SU10. Use response categories from SU20.
Programmer note: For SU51, only ask for drugs reported in SU50. Ask SU51 immediately after subject selects drug in SU50. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU51a-l. Over the past 12 months, in what ways have you used (SU50)? (Check all that apply.)
Programmer note: Use SU11 response categories.
Programmer note: For SU60, only ask for drugs reported in SU50>Never. If none, skip this item.
SU60a-o. Over the past 90 days, how often did you use (SU50)?
☐ Never
☐ Less than once a week
☐ Once a week
☐ More than once a week
☐ Almost every day of the week
Programmer note: For SU61, only ask for drugs reported in SU60 >Never. Ask SU61 immediately after subject selects drug in SU60. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU61a-l. Over the past 90 days, in what ways have you used (SU60)? (Check all that apply.)
Programmer note: Use SU11 response categories.
Programmer note: For SU70, use list of checked responses from SU60 > Never. If none, skip this item.
SU70a-o. Over the past 30 days, how many days did you use (SU60)?
☐ Days (specify 1 - 30) _______
☐ None/Zero days
Programmer note: For SU71, only ask for drugs reported in SU70 > 0. Ask SU71 immediately after subject selects drug in SU70. Do not ask for m, n, and o (inhalents, alcohol, and tobacco)
SU71a-l. Over the past 30 days, in what ways have you used (SU70)? (Check all that apply.)
Programmer note: Use SU11 response categories.
Prescription Opioid Non-Medical Use (PO)
BASE: SU10=a) Prescription opioids used non-medically or b) Prescription opioid treatment medications used non-medically
PO1. How old were you the first time you used prescription opioids non-medically?
___________Age
PO2. The first time you used prescription opioids non-medically, did you have a prescription from a doctor or medical professional for a legitimate medical condition?
☐ Yes
☐ No
PO3. When was the last time you used prescription opioids non-medically?
☐ Today
☐ Past 7 days
☐ Past 30 days
☐ Past 90 days
☐ Past 6 months
☐ Past 12 months
☐ More than 1 year ago
BASE: PO3=1-6 (used in past 12 months)
PO4. In the past 12 months, how many months did you use prescription opioids non-medically? (Enter 1 if less than 1 month.)
☐ Months (specify 1-12) _______
☐ None
BASE: SU10=a) Prescription opioids used non-medically or b) Prescription opioid treatment medications used non-medically
PO5. In the most recent month that you used prescription opioids non-medically, how many days per month did you typically use it?
☐ Days (specify 1-30) _______
☐ None
BASE: PO3=1-4
PO6. Over the past 90 days, how many days did you use prescription opioids non-medically?
☐ Days (specify 1-90) _______
☐ None
BASE: SU10=a) Prescription opioids used non-medically or b) Prescription opioid treatment medications used non-medically
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PO7a-c. How did you acquire the prescription opioids you used non-medically?
a) In lifetime: Check any that apply.
☐ Got from one doctor
☐ Got from more than one doctor
☐ Wrote fake prescription
☐ Stole from Dr. office, clinic, hospital, or pharmacy
☐ Got from friend or relative for free
☐ Bought from friend or relative
☐ Stole from friend or relative
☐ Bought from drug dealer or other stranger
☐ Got some other way (specify): ________
Programmer note: limit list to items checked in PO7a
b) In past 12 months: Check any that apply
c) Most typical way you acquire: Pick one
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PO8a-c. Which of the following prescription opioids you have used non-medically?
a) In lifetime: Check any that apply
☐ Immediate Release Oxycodone (e.g., Percocet, Roxicodone)
☐ Extended Release Oxycodone (e.g. OxyContin OC/OP)
☐ Immediate Release Hydrocodone (e.g., Vicodin)
☐ Extended Release Hydrocodone (e.g., Hysingla, Zohydro)
☐ Buprenorphine (e.g. Suboxone, Subutex)
☐ Methadone
☐ Fentanyl (patch or lollipop)
☐ Morphine (e.g. Embeda, MS-Contin)
☐ Oxymorphone (e.g., Opana)
☐ Hydromorphone (e.g., Dilaudid)
☐ Tramadol (e.g. Ultram)
☐ Codeine (e.g., Tylenol #3)
☐ Meperidine (e.g., Demerol)
☐ Other (specify)
Programmer note: limit list to items checked in PO8a
b) In past 12 months: Check any that apply
c) One I like the best: Pick one
BASE: SU10=a) Prescription opioids used non-medically or b) Prescription opioid treatment medications used non-medically
PO9. The last time you used [One I like the best named in PO11e], what was the dose?
☐ Milligrams (specify) __________
☐ Other units
Specify units _____________
Specify amount in those units ________________
Heroin Use (HU)
BASE: SU10=e) Heroin
HU1. How old were you the first time you used heroin?
__________ Age
BASE: SU10=e) Heroin
HU2. Did you use a prescription opioid (e.g., Duragesic, Percocet, Roxicodone, OxyContin) prior to using heroin for the first time?
☐ Yes
☐ No
BASE: SU10=e) Heroin
HU3. When was the last time you used heroin?
☐ Today
☐ Past 7 days
☐ Past 30 days
☐ Past 90 days
☐ Past 6 months
☐ Past 12 months
☐ More than 1 year ago
BASE: HU3=1-6
HU4. In the past 12 months, how many months did you use heroin?
(Enter 1 if less than 1 month.)
☐ Months (specify 1-12) _______
☐ None
BASE: SU10=e) Heroin
HU5. In the most recent month that you used heroin, how many days per month did you typically use it?
☐ Days (specify 1-30) _______
☐ None
BASE: HU3=1-4
HU6. Over the past 90 days, how many days did you use heroin?
☐ Days (specify 1 - 90) _______
☐ None
BASE: SU10=e) Heroin
HU7. In the most recent month that you used heroin, how much heroin did you typically consume per day? (Select one.)
☐ One small bag
☐ 2-3 small bags
☐ 4-6 small bags
☐ More than 6 small bags
☐ Less than one gram
☐ More than one gram (specify how many grams) _______
BASE: SU10=e) Heroin
HU8. In the most recent month that you used heroin, how many times per day did you typically use it?
Times per day____________
Illicitly-Made Fentanyl (FE)
BASE: SU10=f) Illicitly-made Fentanyl
FE1. How old were you the first time you used illicitly-made fentanyl?
__________ Age
BASE: SU10=f) Illicitly-made Fentanyl
FE2. Did you use a prescription opioid (e.g., Duragesic, Percocet, Roxicodone, OxyContin) prior to using illicitly-made fentanyl for the first time?
☐ Yes
☐ No
BASE: SU10=f) Illicitly-made Fentanyl
FE3. When was the last time you used illicitly-made fentanyl?
☐ Today
☐ Past 7 days
☐ Past 30 days
☐ Past 90 days
☐ Past 6 months
☐ Past 12 months
☐ More than 1 year ago
BASE: FE3=1-6
FE4. In the past 12 months, how many months did you use illicitly-made fentanyl?
(Enter 1 if less than 1 month.)
☐ Months (specify 1-12) ______
☐ None
BASE: SU10=f) Illicitly-made Fentanyl
FE5. In the most recent month that you used illicitly-made fentanyl, how many days per month did you typically use it?
☐ Days (specify 1-30) _______
☐ None
BASE: FE3=1-4
FE6. Over the past 90 days, how many days did you use illicitly-made fentanyl?
☐ Days (specify 1 - 90) _______
☐ None
BASE: All clients not previously sent to END
DO1. Have you ever had a drug overdose in your life?
☐ Yes
☐ No
BASE: BASELINE. DO1>0.
DO2. In the 12 months before you entered your INDEX treatment, how many times did you have a drug overdose?
☐ Times (specify) _______
☐ None
BASE: DO2>0
DO3. In the 12 months before you entered your INDEX treatment, how many times did you overdose due to opioids?
☐ Times (specify) _______
☐ None
BASE: Ask at BASELINE when DO2>0
DO4. In the 90 days before you entered your INDEX treatment, how many times did you have a drug overdose?
☐ Times (specify) _______
☐ None
BASE: Ask at BASELINE when DO4>0
DO5. In the 90 days before you entered your INDEX treatment, how many times did you overdose due to opioids?
☐ Times (specify) _______
☐ None
BASE: Ask at 12, and 24 months when DO1=Yes
DO6. Over the past 12 months, how many times did you have a drug overdose?
☐ Times (specify) _______
☐ None
BASE: DO6>0
DO7. Over the past 12 months, how many times did you overdose due to opioids?
☐ Times (specify) _______
☐ None
BASE: Ask at 12 and 24 months
DO8. Over the past 90 days, how many times did you have a drug overdose?
☐ Times (specify) _______
☐ None
Base: DO8>0
DO9. Over the past 90 days, how many times did you overdose due to opioids?
☐ Times (specify) _______
☐ None
Base: DO1=Yes
Thinking about your last overdose that involved opioids...
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
DO10. Did someone call: (Check all that apply.)
☐ 911 or Emergency Medical Service (EMS)
☐ Police or fire department
☐ Friend (s)
☐ Someone else
☐ None of these apply
Base: DO1=Yes
DO11. Did the Emergency Medical Services come to treat you on site?
☐ Yes
☐ No
Base: DO1=Yes
DO12. Were you administered naloxone?
☐ Yes
☐ No
BASE: DO13=Yes
DO13. Who provided the naloxone?
☐ First responder (Emergency Medical Service /police/fire fighter)
☐ A person with me had naloxone and gave it to me
☐ Other professional (i.e. counselor, CBO staff, etc.)
☐ I had naloxone and someone gave it to me
☐ Other way (specify):_________________________
Base: DO1=Yes
DO14. Were you taken to an Emergency Department?
☐ Yes
☐ No
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
DO15. What other drugs were you on at the time of your overdose? (Check any that apply.)
Programmer
note: Use response categories from SU1.
BASE: All not previously sent to END
CA1. Have you ever been arrested?
☐ Yes
☐ No
BASE: CA1=Yes
CA2. When was the last time you were arrested?
☐ Today
☐ Past 7 days
☐ Past 30 days
☐ Past 90 days
☐ Past 6 months
☐ Past 12 months
☐ More than 1 year ago
BASE: CA2=1-5
CA3. In the past 12 months, how many times have you been arrested? (Include original charges as well as arrests for “failure to appear”.)
☐ Times (specify) _______
☐ None
BASE: CA2=1-3
CA4. In the past 90 days, how many times have you been arrested? (Include original charges as well as arrests for “failure to appear”.)
☐ Times (specify) _______
☐ None
BASE: CA2=1-5
CA5. In the past 12 months, how many nights have you spent in jail or prison?
☐ Times (specify) _______
☐ None
BASE: CA5>0
CA6. In the past 90 days, how many nights have you spent in jail/prison?
☐ Times (specify) _______
☐ None
BASE: All not previously sent to END
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
CA7. Are you currently… (Check any that apply)
☐ awaiting charges, trial or sentencing?
☐ on probation or parole?
☐ on Law Enforcement Assisted Diversion (LED) or Pre-Arrest Diversion (PAD) program?
☐ enrolled in drug court or a remanded drug diversion program?
☐ none of the above
Physical Health Diagnoses (PD)
BASE: All not previously sent to END
PD1a. What sex were you assigned at birth, on your original birth certificate? (GEN)
☐ Male
☐ Female
PD1b. How do you describe your gender identity? (GID)
☐ Male
☐ Female
☐ Male-to-female transgender (MTF)
☐ Female-to-male transgender (FTM)
☐ Other gender identity (specify)_________
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
PD2. Which of the following did a doctor or medical professional ever tell you that you had? (Check any that apply)
☐ Anemia
☐ Arthritis
☐ Asthma
☐ Cancer
☐ Cirrhosis of the liver
☐ Diabetes Type I
☐ Diabetes Type II
☐ Fibromyalgia
☐ Heart Disease
☐ Hepatitis C
☐ High Blood Pressure (Hypertension)
☐ HIV/AIDS
☐ Osteoporosis
☐ Pancreatitis
☐ Pneumonia
☐ Sexually Transmitted Disease (e.g. chlamydia, herpes, syphilis, gonorrhea)
☐ Sleep apnea
☐ Stroke
☐ Tuberculosis
☐ Ulcer(s)
☐ Other condition/none of the above
Pregnancy (PO)
BASE: PD1=female
PO1. Have you ever been pregnant?
☐ Yes
☐ No
BASE: PO1=Yes
Thinking about your last pregnancy...
PO2. Did you use prescription opioids or heroin while you were pregnant?
☐ Yes
☐ No
PO3. Did your last pregnancy result in a live birth?
☐ Yes
☐ No
BASE: PO3=Yes
PO4. Was your newborn diagnosed with neonatal abstinence syndrome (e.g. opioid withdrawal)?
☐ Yes
☐ No
BASE: PO1=Yes
BASE: BASELINE, 12 MONTH, 24 MONTH
PO5. Are you currently pregnant?
☐ Yes
☐ No
☐ I don’t know/ would rather not say
HIV (HV)
BASE: All not previously sent to END
HV1. Have you ever been tested for HIV/AIDS?
☐ Yes
☐ No
BASE: HV1=Yes
HV2. Date of your most recent HIV test
MM/DD/YY
BASE: HV1=Yes
HV3. Do you know the results of your most recent HIV test?
☐ No, I took the test but did not get the result
☐ Yes, it was negative
☐ Yes, it was positive
BASE: HV3=3 (Yes, it was positive)
HV4. Are you currently taking medications for your HIV/AIDS?
☐ Yes
☐ No
HEP-C (HC)
BASE: All not previously sent to END
HC1. Have you ever been tested for Hepatitis C?
☐ Yes
☐ No
BASE: HC1=Yes
HC2. Date of your most recent Hepatitis C test?
MM/DD/YY
BASE: HC1=Yes
HC3. Do you know the results of your most recent Hepatitis C test?
☐ No, I took the test but did not get the result
☐ Yes, it was negative
☐ Yes, it was positive
BASE: HC3=3 (Yes, it was positive)
HC4. Did you receive treatment for Hepatitis C?
☐ Yes
☐ No
Analyst note: Quality of Life EQ-5D (EQ)
The following questions are about your health and well-being.
BASE: All not previously sent to END
EQ1. How is your mobility?
☐ I have no problems in walking about
☐ I have slight problems in walking about
☐ I have moderate problems in walking about
☐ I have severe problems in walking about
☐ I am unable to walk about
EQ2. How well can you care for yourself?
☐ I have no problems washing or dressing myself
☐ I have slight problems washing or dressing myself
☐ I have moderate problems washing or dressing myself
☐ I have severe problems washing or dressing myself
☐ I am unable to wash or dress myself
BASE: All not previously sent to END
EQ3. How are you at regular activities (e.g. work, study, housework, family or leisure activities)?
☐ I have no problems doing my usual activities
☐ I have slight problems doing my usual activities
☐ I have moderate problems doing my usual activities
☐ I have severe problems doing my usual activities
☐ I am unable to do my usual activities
BASE: All not previously sent to END
EQ4. How is your pain or discomfort?
☐ I have no pain or discomfort
☐ I have slight pain or discomfort
☐ I have moderate pain or discomfort
☐ I have severe pain or discomfort
☐ I have extreme pain or discomfort
BASE: All not previously sent to END
EQ5. How is your anxiety or depression?
☐ I am not anxious or depressed
☐ I am slightly anxious or depressed
☐ I am moderately anxious or depressed
☐ I am severely anxious or depressed
☐ I am extremely anxious or depressed
BASE: All not previously sent to END
EQ6. We would like to know how good or bad your health is today. (This scale is numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. Enter a number from 1 to 100.)
My health today is: ______
How You are Feeling Physically (BF)
Analyst note: This is BRFSS Quality of Life items
BASE: All not previously sent to END.
BF1. Would you say that in general your health is:
☐ Excellent
☐ Very good
☐ Good
☐ Fair
☐ Poor
BF2. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
These next questions are about physical, mental, or emotional problems or limitations you may have in your daily life.
BF5. Are you LIMITED in any way in any activities because of any impairment or health problem?
☐ Yes
☐ No
Base: BF5=Yes
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
BF6. What is the one MAJOR impairment or health problem that limits your activities? (Select one)
☐ Arthritis/rheumatism
☐ Back or neck problem
☐ Fractures, bone/joint injury
☐ Walking problem
☐ Lung/breathing problem
☐ Hearing problem
☐ Eye/vision problem
☐ Heart problem
☐ Stroke problem
☐ Hypertension/high blood pressure
☐ Diabetes
☐ Cancer
☐ Depression/anxiety/emotional problem
☐ Other impairment/problem
Base: BF5=Yes
BF7. For how long have your activities been limited because of your major impairment or health problem?
Days _ _
Weeks _ _
Months _ _
Years _ _
Base: All not previously sent to END
BF8. Because of any impairment or health problem, do you need the help of other persons with your personal care needs, such as eating, bathing, dressing, or getting around the house?
☐ Yes
☐ No
BF9. Because of any impairment or health problem, do you need the help of other persons in handling your routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
☐ Yes
☐ No
BF10. During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF11. During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF12. During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF13. During the past 30 days, for about how many days have you felt you did NOT get ENOUGH REST or SLEEP? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
BF14. During the past 30 days, for about how many days have you felt VERY HEALTHY AND FULL OF ENERGY? (Check None if zero days.)
☐ Days (specify 1-30) _______
☐ None
Emotional and Mental Health Diagnoses (MD)
BASE: All not previously sent to END
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
MD1. Have you ever been diagnosed with any of the following conditions? (Check any that apply)
☐ Major Depression/Clinical Depression
☐ Bi-Polar Disorder/ Mania/Manic Depression
☐ Dysthymia
☐ Generalized Anxiety Disorder
☐ Phobia (e.g. specific phobias like spiders, or general phobias like agoraphobia)
☐ Post-Traumatic Stress Disorder/PTSD
☐ Panic Disorder
☐ Conduct Disorder (before age 18)
☐ Personality Disorder (e.g., Borderline Personality Disorder, Anti-social Personality Disorder)
☐ Intermittent Explosive Disorder
☐ Attention-Deficit Hyperactivity Disorder (ADHD)
☐ Obsessive-Compulsive Disorder
☐ Eating Disorder (e.g., Anorexia Nervosa, Binge Eating Disorder)
☐ Other Mental Health Condition
☐ None
The next two questions ask about suicide.
MD2. At any time in the past 12 months, did you seriously think about trying to kill yourself?
☐ Yes
☐ No
MD3. During the past 12 months, did you try to kill yourself?
☐ Yes
☐ No
Stress (PS)
Analyst note: This is Perceived Stress Scale (PS)
BASE: All not previously sent to END
Programmer note: Randomly order list.
PS1a-j. The questions in this scale ask about your feelings and thoughts in the past 30 days. In each case, you will be asked to indicate by marking how you felt a certain way. In the past 30 days, how often have you....
a). ...Been upset because of something that happened unexpectedly?
☐ Never
☐ Almost never
☐ Sometimes
☐ Fairly often
☐ Very often
b). ...Felt you were unable to control the important things in your life?
c). ...Felt nervous and stressed?
d). ...Felt confident about your ability to handle your personal problems?
e). ...Felt that things weren't going your way?
f). ...Found that you could not cope with all the things you had to do?
g). ...Been able to control irritations in your life?
h). ...Felt you were on top of things?
i). ...Been angered because things were out of your control?
j). ...Felt difficulties were piling up so high that you could not overcome them?
How You are Feeling Emotionally (PQ)
Analyst note: This is Depression Module - PHQ-8 (PQ)
BASE: All not previously sent to END
Programmer note: Randomly order list.
PQ1a-h. Over the past 2 weeks, how often have you been bothered by any of the following problems?
a) Little interest or pleasure in doing things
☐ Not at all
☐ Several days
☐ More than half the days
☐ Nearly every day
b) Feeling down, depressed, or hopeless
c) Trouble falling or staying asleep, or sleeping too much
d) Feeling tired or having little energy
e) Poor appetite or overeating
f) Feeling bad about yourself — or that you are a failure or have let yourself or your family down
g) Trouble concentrating on things, such as reading the newspaper or watching television
h) Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Analyst note: This is PTSD Scale (PT)
BASE: All not previously sent to END
Programmer note: Do NOT randomly order list.
PT1a-d. In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past 30 days, you
a) ... Have had nightmares about it or thought about it when you did not want to?
☐ Yes
☐ No
b) ... Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
c) ...Were constantly on guard, watchful or easily startled?
d) ... Felt numb or detached from others, activities, or your surroundings?
Programmer Note: This is perceived Social Support Scales (SS)
BASE: All not previously sent to END.
Programmer note: Randomly order list.
SS1a-l. We are interested in how you feel about the following statements. Would you say you:
There is a special person who is around when I am in need.
☐ Very Strongly Agree
☐ Strongly Agree
☐ Mildly Agree
☐ Neutral
☐ Mildly Disagree
☐ Strongly Disagree
☐ Very Strongly Disagree
There is a special person with whom I can share my joys and sorrows.
My family really tries to help me.
I get the emotional help and support I need from my family.
I have a special person who is a real source of comfort to me.
My friends really try to help me.
I can count on my friends when things go wrong.
I can talk about my problems with my family.
I have friends with whom I can share my joys and sorrows.
There is a special person in my life who cares about my feelings.
My family is willing to help me make decisions.
I can talk about my problems with friends.
Programmer note: This is Stigma Perception Scale (SG)
BASE: BASELINE
Programmer note: Randomly order list.
SG1. Please tell us how much you agree or disagree with the following statements.
I avoid being friends with people who don't use drugs.
☐ Strongly Agree
☐ Agree
☐ Disagree
☐ Strongly Disagree
I put a lot of effort into hiding my substance use history.
Shame gets in the way of how I live my life.
I often lie to people about my substance use if I know they could never find out the truth.
I often blame my substance use history for many things that do NOT go my way in life.
We would like to ask you some questions about events that happened during your childhood. This information will allow us to better understand problems that may occur early in life, and may help others in the future. All questions refer to the time period before you were 18 years of age.
Now, looking back before you were 18 years of age…
BASE: BASELINE
AC1. Did you live with anyone who was depressed, mentally ill, or suicidal?
☐ Yes
☐ No
☐ Don’t Know/Prefer not to say
AC2. Did you live with anyone who was a problem drinker or alcoholic?
☐ Yes
☐ No
☐ Don’t Know/Prefer not to say
AC3. Did you live with anyone who used illegal street drugs or who abused prescription medications?
☐ Yes
☐ No
☐ Don’t Know/Prefer not to say
AC4. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
☐ Yes
☐ No
☐ Don’t Know/Prefer not to say
AC5. How often did your parents or adults in your home ever slap, hit, kick, punch, beat, or physically hurt each other?
☐ Never
☐ Once
☐ More than once
☐ Don’t know/prefer not to say
AC6. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.
☐ Never
☐ Once
☐ More than once
☐ Don’t know/prefer not to say
AC7. How often did a parent or adult in your home ever swear at you, insult you, or put you down?
☐ Never
☐ Once
☐ More than once
☐ Don’t know/prefer not to say
AC8. Did anyone at least 5 years older than you or an adult, ever touch you sexually, try to make you touch them sexually, or force you to have sex?
☐ Yes
☐ No
☐ Don’t Know/Prefer not to say
AC9. How often was there an adult in your household who tried hard to make sure your basic needs were met?
☐ Never
☐ Rarely
☐ Sometimes
☐ Most of the time
☐ Always
☐ Don’t Know/Prefer not to say
AC10. How often was there an adult in your household who made you feel safe and protected?
☐ Never
☐ Rarely
☐ Sometimes
☐ Most of the time
☐ Always
☐ Don’t Know/Prefer not to say
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
HI1. Do you have any of the following types of health insurance? (Check all that apply.)
☐ Insurance plan through current/former employer or union
☐ Insurance through someone else’s work plan (e.g., spouse/domestic partner, parent, or other)
☐ Privately purchased insurance
☐ Medicare
☐ Medicaid
☐ Veterans Administration-provided insurance
☐ Other
☐ No, I don't have health insurance
BASE: HI1=1-7
HI2. Does your health insurance cover any part of the costs associated with medication-assisted treatment services (i.e., methadone, buprenorphine, naltrexone)?
☐ Yes, most (75% or more of the costs)
☐ Yes, some (less than 75% but more than 25% of the costs)
☐ Yes, Very Little (less than 25%)
☐ None
BASE: HI1=1-7
HI3. Does your health insurance cover any part of the costs associated with counseling services for treatment of substance abuse?
☐ Yes, most (75% or more of the costs)
☐ Yes, some (less than 75% but more than 25% of the costs)
☐ Yes, Very Little (less than 25%)
☐ None
Select the answer that best describes your current situation.
BASE: All clients not previously sent to END
D1. Your date of birth (DOB)
MM/DD/YY
BASE: All clients not previously sent to END; baseline only
Programmer note: Do NOT randomly order list. Checked=1, not checked=0
D1. Are you Hispanic or Latino? (ETH)
☐ Yes
☐ No
D2. What is your race? (RCE) (Check all that apply.)
☐ White
☐ Black or African American
☐ American Indian
☐ Alaska Native
☐ Asian
☐ Native Hawaiian or other Pacific Islander
☐ Other
Programmer note: Do NOT randomly order list.
D3. Which of the following best represents how you think of yourself? (SXP)
☐ Lesbian or gay
☐ Straight, that is not lesbian or gay
☐ Bisexual
☐ Something else
☐ I don’t know theanswer
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
D4. Your current marital status. (MAS)
☐ Single, never married
☐ Married or domestic partnership
☐ Divorced or separated
☐ Widowed
☐ Other
BASE: All clients not previously sent to END
D5. ZIP code of your current residence (ZIP)
ZIP Code
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
D6. Where have you lived most of the time over the...
[BASELINE:
...12 months prior to entering INDEX treatment/
12MONTH and 24MONTH:
...past 12 months] ?. (HOU)
☐ House or condo I own
☐ House, apartment, or room I rent or have permission to live in
☐ Dormitory or college residence
☐ Hotel room
☐ SRO housing (single room occupancy housing)
☐ Residential treatment center
☐ Halfway house (e.g., sober house)
☐ Shelter (e.g., temporary day or evening facility)
☐ Outdoors (e.g., on the street, abandoned building, public park)
☐ Jail/prison
☐ Hospital/long-term residential care facility/nursing home
☐ Other (specify) ________________________
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
D7a-h. Who have you lived with most of the time over the...
BASELINE:
...12 months prior to entering INDEX treatment/
12MONTH and 24MONTH:
...past 12 months](Check all that apply) (LIV)
☐ With my spouse/ partner
☐ With my children
☐ With my parents
☐ With other immediate family (siblings, grandparents)
☐ With friends/roommates
☐ No one else
☐ Other (e.g., live in jail, shelter, homeless)
BASE: All clients not previously sent to END
Programmer note: Do NOT randomly order list.
D8. Your highest degree or level of school that you have completed. (If you are currently enrolled in school, tell us the highest degree received.) (SCH)
☐ 8th grade or lower
☐ Some high school but no diploma
☐ High school diploma or equivalent (e.g., GED)
☐ Some vocational/technical training after high school, but no degree
☐ Vocational/technical diploma after high school
☐ Some college credit, but no degree
☐ Associate degree
☐ Bachelor’s degree
☐ Master's degree/Doctoral degree/Professional degree
☐ Other
D9. Are you currently enrolled in school or in a job training program? (TRN)
☐ Enrolled, full time
☐ Enrolled, part time
☐ Not enrolled
☐ Other
D10. Have you ever served in the United States Armed Forces, in the Reserves, or in the National Guard? (MIL)
☐ Yes, currently serving
☐ Yes, currently separated or retired
☐ No
Programmer note: Do NOT randomly order list.
D11. How [SS2=Yes:do/ SS2=No:did] you usually get to your appointments at (FACILITY)? (If you (use/used) multiple methods, tell us the one you (use/used) most.) (TRN)
☐ Car, truck or van driven by you
☐ Car, truck or van driven by your family or friends
☐ Public transportation (e.g., bus, subway)
☐ Taxi cab or car service (e.g., Uber, Lyft)
☐ Motorcycle
☐ Bicycle
☐ Walk
☐ I lived at (FACILITY)
☐ Other
Thank You
Thank you for completing the survey!
[Message if in person with RTI interviewer]
Thank you for completing the survey. Your interviewer will now make arrangements for your incentive payment.
[Message if online with no interviewer]
Thank you for completing the survey. Click the button below to collect your incentive payment.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | McMillan, Mary |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |
© 2024 OMB.report | Privacy Policy