A 32-year-old male with a 6-year history of heroin use disorder presents to the de-addiction centre. He has been using 2–3 grams of heroin daily and wishes to discontinue. He has no active medical comorbidities and is motivated for treatment. What is the most appropriate next step in management?

Explanation

## Initial Assessment in Opioid Use Disorder **Key Point:** The first step in any substance use disorder management is a comprehensive assessment — not immediate pharmacotherapy. This establishes baseline severity, comorbidities, psychosocial stressors, and readiness for change. ### Why Comprehensive Assessment Comes First 1. **Baseline urine drug screening** confirms opioid use and screens for concurrent use of other substances (benzodiazepines, stimulants, alcohol). 2. **Biopsychosocial assessment** evaluates: - Severity of dependence (COWS or OARRS scale) - Psychiatric comorbidities (depression, anxiety, PTSD) - Social support, employment, housing - Medical complications (hepatitis C, HIV, endocarditis) - Motivation and treatment readiness 3. **Informs treatment choice**: The assessment determines whether the patient is suitable for outpatient maintenance (methadone or buprenorphine) vs. inpatient detoxification vs. naltrexone-based therapy. ### Treatment Pathway After Assessment ```mermaid flowchart TD A[Opioid Use Disorder presents]:::outcome --> B[Comprehensive assessment + UDS]:::action B --> C{Severity & Readiness?}:::decision C -->|Moderate-severe, motivated| D[Maintenance therapy: Methadone or Buprenorphine]:::action C -->|Mild, high motivation| E[Naltrexone-based therapy]:::action C -->|Acute withdrawal risk| F[Inpatient detoxification]:::action D --> G[Long-term psychosocial support]:::action E --> G F --> G ``` **High-Yield:** In India, the Narcotic Drugs and Psychotropic Substances (NDPS) Act mandates reporting and regulated access to opioid agonist therapies. Assessment ensures compliance with legal and clinical standards. **Clinical Pearl:** Even a highly motivated patient should not skip assessment — it identifies hidden comorbidities (e.g., untreated depression, active hepatitis C) that affect treatment outcomes. **Tip:** Methadone and buprenorphine are the gold-standard maintenance therapies; naltrexone is reserved for highly motivated, abstinence-focused patients with good psychosocial support.