COMMONWEALTH OF MASSACHUSETTS
Executive Office of Health and Human Services
Department of Public Health

Enterprise Invoice Management 
 Enterprise Service Management 

 BSAS
Opioid Treatment Enrollment Assessment Manual

Version 8

January 2019

Introduction
Why Do We Collect this Data and Why is Accuracy Important?
Goals and Objectives
Client Confidentiality
Why is the collection of identifying information so important?
Interview Assumptions
Opioid Treatment Enrollment Assessment
	Enrollment Date
	ESM Client ID
Provider ID
First Name/Middle Initial/Last Name/Suffix
1.	 Client Code
2.	 Intake/Clinician Initials:
3.	 Do you own or rent a house, apartment, or room?
4.	 Are you ‘Chronically Homeless’?
5. 	 Enter the Zip Code of the Person’s Last Permanent Address:
6. 	 Where did you stay last night?
7a	 Do you consider yourself to be transgender?
7b.	 If you answered Yes to Q4, please specify:
8.	 Do you consider yourself to be:
9.	 Number of days between initial contact with the program by the client or someone on behalf of the client and 
               enrollment*

10.	  Source of Referral
11.	  Frequency of attendance at self-help programs
12.	 Additional Client Type
13.	  Do you have children?
13a.	Number Children Under 6:
13b	Number of Children 6-18:
13c.	Children Over 18:
13d.  Are any of your children of the Native American race? (i.e., American Indian)
14.	 Are you the primary caregiver for any children?
15.	 Employment at the time of Enrollment
16.	 Number of days worked last 30 days
17.	 Where do you usually live? *
18.	 Who do you live with?
19.	 Use of Mobility Aid
20.	 Vision Impairment
21.	 Hearing Impairment
22.	 Self-Care/ADL Impairment
23.	 Developmental Disability
24.	 Prior Mental Health Treatment
25.	 During the last 12 months, did you take any prescription medication that was prescribed for you to treat a mental
                or emotional condition?

26.	 Number of prior admissions to each substance addiction treatment modality
27.	 Currently receiving services from a state agency
28.	 Number of arrests in the last 30 days
29.	 History – Substance Mis-Use / Nicotine/Tobacco / Gambling
Have you ever used?
Last Use
Usual Route of Administration
30a        Number of cigarettes currently smoked per day
30b. 	    Interest in stopping nicotine/tobacco use
31a.	    Types of last regular gambling
31b. 	    Have you ever thought you might have a gambling problem or been told you might?
32.	 Ranking of Substances
33.	 Last Needle Use
34.	  Have you had any overdoses in your lifetime?
34a.	  How many overdoses have you had in your lifetime?
34b.	  How many overdoses have you had in the past year?
MTQAS/OTP (Opiate Treatment Program) Questions
1. 	  Is your current medication-assisted treatment for withdrawal management or maintenance?
2. 	  Are you receiving a prescription for Suboxone or Vivitrol
2a	 If yes, select the medication prescribed.
2b	 Is this prescription for opioid use disorder, alcohol use disorder, or both
3.	 Current Criminal Justice Status
4.	  Number of Arrests in Lifetime
5.	  Frequency of Injected Drug Use in the Past 12 Months
6.	 In general, how would you describe your current health?
7.	  During the past 12 months, how much difficulty did you have doing your daily activities, both inside and outside 
                 the home, due to physical or emotional problems?

8.	 During the past 12 months, how many nights were you hospitalized for physical problems?
9.	 During the past 12 months, how many nights were you in a detox facility?
10.	 During the past 12 months, how many visits to an emergency room/or urgent care facility did you make?
11.	  In the past 12 months, how much were you distressed (bothered) by..

12.	  In the past 12 months, how much were you distressed (bothered) by …
13.	 Did you stay overnight somewhere for treatment of problems with your emotions, nerves, or mental health?
14.	  Did you ever get outpatient treatment or counseling for an emotional or mental health problem?
15.	 In the past 12 months, did you think about suicide?
16.	  In the past 12 months, did you attempt suicide?
17.	 How supportive would you say the people closest to you are of your seeking substance addiction treatment at this
                 time?

18.	 Would you say that none of the people, a few of the people, or most of the people you are close to are  
                currently abusing drugs?

 
Introduction

The Department of Public Health (DPH), Bureau of Substance Abuse Services (BSAS) collects client and service data via the Executive Office of Health and Human Services (EOHHS) business application, Enterprise Invoice Management-Enterprise Service Management (EIM-ESM), which is accessed through the web-based EOHHS Virtual Gateway. 

Why Do We Collect this Data and Why is Accuracy Important?

At least half of the funding for substance abuse services is Federal.  BSAS reports to the Substance Abuse and Mental Health Services Administration (SAMHSA). 

•	It is a federal reporting requirement that we submit this data to SAMHSA
•	The data submitted to SAMHSA is referred to as the Treatment Episode Data Set (TEDS)
•	TEDS is the ONLY national client-level database on substance abuse treatment
	The data is used by federal policymakers, researchers, and many others
•	It provides data for trend analysis, understanding characteristics of persons admitted
	to substance abuse treatment and client outcomes
•	It includes information on all clients admitted to programs that receive public funds

•	Performance Management
•	Level of Care Management meeting process
•	Development of provider feedback reports
	Business Decision Support
	Analysis to determine client outcomes and to promote best practices

EIM-ESM is designed to provide timely and comprehensive reports on client characteristics at Intake and Enrollment, client status at Disenrollment, and client change between the beginning and end of the treatment episode.  The data system can be used to monitor treatment time and readmission rates for the same or different substance abuse problems.  An important dimension of the system is that client and fiscal information systems use the same database.  As a result, program managers may obtain detailed information on the type and amount of services provided and the cost of services to specific client groups.
Goals and Objectives
The primary goal of the EIM-ESM data collection by the Bureau of Substance Abuse Services is to enhance fiscal and program management.  To achieve that goal, the system has eight objectives:

1.	Provide unduplicated client count
2.	Provide count of client enrollments
3.	Monitor usage patterns
4.	Provide timely reports on client characteristics
5.	Verify billing and suspend payment if necessary
6.	Compute utilization rates
7.	Produce budget status reports
8.	Facilitate treatment and recidivism studies
Client Confidentiality

The Bureau realizes that there is concern as to client confidentiality because client names and other identifying information such as Social Security numbers (SSN) are collected by EIM-ESM.  Not only does the Bureau adhere to the provision governing the confidentiality of alcohol and drug abuse patient records (Code of Federal Regulations, Chapter 42, Part II), but in addition the data is protected by HIPAA and by the Massachusetts Fair Information Practices Act. The data qualify as medical records and, therefore, cannot be requested as “public records”.

•	The EIM-ESM security measures are robust.  It is an award winning security system.  The Department of Public Health’s Legal Office determined that BSAS staff, including any research or analytic staff, should have no access to the EIM-ESM interface, unless required to meet their job responsibilities such as Provider Support and Technical Assistance. The DPH EIM-ESM Management Office that does have access to the interface, not only abides by the Confidentiality Agreements, but are housed in locked offices to assure that no accidental viewing of the interface can occur.  

•	The database stores the information in separate unidentified tables.  Data managers are not able to search the database using identified client information.

•	In addition, there is a Qualified Service Organization Agreement (a signed and dated document describing the agreed upon terms of a service relationship between the licensee and the qualified service organization, which meets the requirements of 42 CFR Part 2), between DPH and EOHHS which assures that access to client screens is not permitted by any EOHHS staff supporting the EIM-ESM application. 
Why is the collection of identifying information so important?
•	Entering identified information enables providers to link a client’s enrollments.

•	Without it the Bureau could not meet its goals to 
o	report accurate client outcomes and 
o	enhance treatment opportunities.

•	EIM-ESM limits access to a client’s enrollment information and substance addiction assessment information to the organization that is treating the client and holds the consent to enter the data into EIM-ESM.

•	Only the enrolling agency can see that the client is enrolled in a BSAS Program.
 
Tips
•	Never email client names when contacting DPH for technical assistance
•	Never use the client name when on a phone call with DPH for technical assistance

Interview Assumptions
The BSAS Intake and Assessments interviews are based on two important assumptions:

1.	The Bureau’s Intake/Assessment interviews are not designed as clinical interviews.  Although general descriptions of client status are obtained, the detail required for a comprehensive analysis of the client’s substance abuse and related problems is not elicited.  Programs, therefore, are expected to conduct more detailed clinical interviews.  Collection of the Assessment data can be a part of the more comprehensive clinical interview.

2.	Many of the interview items are designed as prompts.  
	A specific question format is not provided. Clinicians are free to ask the questions in their own style and format.  The only constraint is that all required questions must be asked and an answer provided even when it is “unknown’ or “refused”.

Opioid Treatment Enrollment Assessment

All questions marked with   are required and must be completed. 
	Enrollment Date
Enter the day that the client was enrolled/admitted to the program.  Enter the date using the MM/DD/YYYY format.  MM must be 01 through 12 and DD must be 01 through 31 (e.g. 06/01/2007). The Enrollment Date is entered in EIM-ESM once the Assessment is completed and submitted. 
	ESM Client ID
The Client ID is automatically assigned when the client is entered into the ESM-EIM system.  This number should be recorded on the Intake form after the data is entered into EIM-ESM system.  As the Bureau does not have access to client names, this is helpful information to have in the client record when verifying the data in the system or when communicating with the Bureau regarding the specific client’s case and/or billing.
Provider ID
This field is to be used by the provider in any way that is helpful to them in the management of client records.  This is not entered into the EIM-ESM system.
First Name/Middle Initial/Last Name/Suffix
While the client name is only entered into the Application at Intake, writing the full legal names on the Enrollment and Disenrollment Assessment forms is good record management.

1.		Client Code
The Client Code is a five character code composed of capital letters from the individual’s full name:
1.	First letter of the client’s first name
2.	Third letter of the client’s first name
3.	Middle initial (If none, enter 4)
4.	First letter of the client’s last name
5.	Third letter of the client’s last name 

The Client Code was used to monitor multiple enrollments across years when EIM-ESM was not implemented and there was no unique Client ID assigned by a system.  This is still used by the Federal funding source, The Center for Substance Abuse Treatment, CSAT, to link records across years when monitoring substance addiction treatment utilization and trends.

Be sure to base the Client Code on the individual’s full legal name.   
•	Do not use shortened names, such as Bill for William or nicknames such as Buddy.  
•	Also, try to obtain the middle initial.  
•	Taking these steps will ensure the quality of data analysis where the Client Code is being used, in part, to uniquely identify clients.

If the individual’s first or last name does not have three letters, use a 4 in place of the third letter.  

.

2.		Intake/Clinician Initials:
Enter the initials of the clinician who conducted the enrollment assessment interview.

3.		Do you own or rent a house, apartment, or room?
Check only one box. 
The choices are:
•	Yes
•	No

If the client answers ‘Yes’ to Question 3, Skip Question 3a and go to Question 3b.
If the client answers ‘No’ to Question 3, Question 3a must be answered.
4.		Are you ‘Chronically Homeless’? 
check only one box.  
The choices are:
•	Yes
•	No

Read the HUD definition, below, of a chronically homeless person before answering this question.

HUD definition of a chronically homeless person:
‘A person who is ‘chronically homeless’ is an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years.  In order to be considered chronically homeless, a person must have been sleeping in a place not meant for human habitation (e.g., living on the streets) and/or in an emergency homeless shelter.’  A disabling condition is defined as ‘a diagnosable substance use disorder, serious mental illness, developmental disability, or chronic physical illness or disability, including the co-occurrence of two or more of these conditions.’  A disabling condition limits an individual’s ability to work or perform one or more activities of daily living.  An episode of homelessness is a separate, distinct, and sustained stay on the streets and/or in an emergency homeless shelter.  A chronically homeless person must be unaccompanied and disabled during each episode.’

5. 		Enter the Zip Code of the Person’s Last Permanent Address:
•	Do Not enter the zip code of Program.  
•	This is the person’s last PERMANENT address.  
•	
This question serves to show the migration of populations and if clients are leaving an area in order to obtain services.

They may be homeless in Boston but their last permanent address goes back a year or more to a family residence
6. 		Where did you stay last night?
Check only one box. 
 If ‘Other’ is selected specify the place. 
The choices are:
•	1. Emergency shelter
•	2. Transitional housing for homeless persons (Not a TSS Program)
•	3. Permanent housing for formerly homeless
•	4. Psychiatric hospital or other psychiatric facility
•	5. Substance addiction treatment facility or detox
•	6. Hospital (non-psychiatric)
•	7. Jail, prison or juvenile detention facility
•	8. Room, apartment, or house that you own or rent
•	9. Staying or living with a family member
•	10. Staying or living with a friend 
•	11. Room, apartment, or house to which you presently cannot return (future return may be uncertain)
•	12. Hotel or motel paid for without emergency shelter voucher
•	13. Foster care home or foster care group home
•	14 Place not meant for habitation
•	15 Other, specify______________________________________
•	88 Refused
7a	Do you consider yourself to be transgender?
Check only one box.
The choices are  
•	1  Yes
•	2  No
•	88 Refused
7b.		If you answered Yes to Q4, please specify:             
Check only one box.  If ‘Other’ is selected, please specify: (e.g. Intersex)
The choices are:
•	Male to Female
•	Female to Male
•	Other, specify________________________________________
8.		Do you consider yourself to be:
Check only one box.  If ‘Other’ is selected, please specify:  (e.g., Queer)
The choices are:
•	Heterosexual
•	Gay/Lesbian
•	Bisexual
•	Other, specify__________________________________________
•	Refused

9.	    Number of days between initial contact with the program by the client or someone on behalf 
       of the client and enrollment*
•	Enter the number of days from first request to first bed/appointment availability*.  
•	In outpatient settings, the client’s wait time is zero if the earliest appointment is offered but the client requests a later date

The purpose of this question is to monitor waiting lists and capacity needs.  
Please note:  This is the only instance when ‘Unknown’ is coded as 999, at all other times it will be 99.

10.	  Source of Referral 
Enter one code from the following choices.  You must enter 2 digits with leading zeroes for the entry to be valid.  

Please pay close attention to the code numbers as series of numbers have been discontinued, some choices edited and choices added.

The choices are:
01	Self, Family, Non-medical Professional	
02	BMC Central Intake/Room 5	
03	ATS/Detox	
04	Transitional Support Services/TSS	
05	Clinical Stabilization Services/CSS-CMID	
06	Residential Treatment	
07	Outpatient SA Counseling	
08	Medication Assisted Treatment	
09	Drunk Driving Program	
10	Acupuncture	
11	Gambling Program	
	Note: Sec 35 Options are grouped although numbers are not in sequence. Select correct #	
12	Sec 35 (WATC & MATC)	
24	Sec 35 Bridgewater MASAC	
25	Sec 35 Framingham MCI	
	13 Discontinued	
14	Sober House	
16	Recovery Support Centers	
15	Information and Referral	
17	Second Offender Aftercare	
18	Family Intervention Program	
19	Other Substance Abuse Treatment	
20	Health Care Professional, Hospital	
21	Emergency Room	
22	HIV/AIDS Programs	
23	Needle Exchange Programs	
	24 through 25 Discontinued	
26	Mental Health Professional	
	27 through 29 Discontinued	
30	School Personnel, School System/Colleges	
31	Recovery High School 	
	31 through 39 Discontinued 	
40	Supervisor/Employee Counselor	
	41 through 49 Discontinued	
50	Shelter	
51	Community or Religious Organization	
	52 through 58 Discontinued	
59	Drug Court	
60	Court - Section 35	
61	Court - DUI	
63	Court - Other	
64	Prerelease, Legal Aid, Police	
65	County House of Corrections/Jail	
66	Office of Community Corrections	
67	Department of Corrections	
68	Office of the Commissioner of Probation	
69	Massachusetts Parole Board	
70	Dept. of Youth Services	
71	Dept. of Children and Families	
72	Dept. of Mental Health	
73	Dept. of Developmental Services	
	74 through 76 Discontinued	
77	Mass. Rehab. Commission	
78	Mass. Commission for the Blind	
79	Mass. Comm. For Deaf & Hard of Hearing	
80	Other State Agency	
81	Discontinued	
99	Unknown	

11.	 	Frequency of attendance at self-help programs
Enter the code that corresponds to number of times a client reports having attended a self-help program (e.g. AA, NA etc…) in the 30 days prior to Enrollment

The choices are: 
01 - No attendance in the past month
02 - 1-3 times in past month (less than once per week)
03 - 4-7 times in past month (about once per week)
04 - 8-15 times in past month (2 or 3 times per week)
05 - 16-30 times in past month (4 or more times per week)
06 - Some attendance in past month, but frequency unknown
99 - Unknown
12.		Additional Client Type  
Check only one box for each sub-question 9a-9i
The choices are: Yes/No

•	For Client Type Prison the valid answer is “No”

12a. Student:  Clients enrolled in any type of formal/vocational education. 
•	Yes    
•	No

12b. Pregnant: Clients pregnant at the time of enrollment.
•	Yes    
•	No
  
12c. Postpartum: Postpartum is defined as the period between delivery and up to one year post delivery.
•	Yes    
•	No

12d. Prison: Select No
•	Yes    
•	No

12e. Probation: Probation clients are under the supervision of the Office of the Commissioner of Probation.  The client’s 
                           substance addiction treatment may or may not be mandated as a condition of his/her probation.
•	Yes    
•	No

12f. Parole: Parole clients are under the supervision of the Massachusetts Parole Board.
•	Yes    
•	No

12g. Federal Probation:  Federal probation clients are under the supervision of the Federal government.
•	Yes    
•	No

12h. Federal Parole: Federal parole clients are under the supervision of the Federal government.
•	Yes    
•	No

13.			Do you have children?
Check only one box. 
•	1  Yes
•	2  No
•	88 Refused

•	If the client selects ‘No’ or ‘Refused’, skip to Question 14.
•	If the client selects ‘Yes’, answer Questions 13a-13d.
13a.	Number Children Under 6:
Enter number of children less than 6 years of age.
13b	Number of Children 6-18:
Enter number of children between the ages of 6 and 18 years.
13c.	Children Over 18:
Enter number of children over 18 years of age.
13k.	13d.	Are any of your children of the Native American race? (i.e., American Indian)
If the child is Native American, it is EOHHS policy that every effort is made to  assure the child is living with a Native American family. This information is helpful when consulting with DCF.

Check only one box. 
The choices are:
•	Yes
•	No

14.		Are you the primary caregiver for any children?
Check only one box. 
The choices are:
•	Yes
•	No

If the client is the primary caregiver of children you must assess as to the children’s welfare and what arrangements have been made for their care in your full clinical assessment

•	If the client is involved with DCF and has an open service plan, the client should contact the DCF case manager. If the client doesn’t know how to reach the DCF social worker, call the area office (list of offices can be found at www.mass.gov/DCF.

•	For a list of Child Care Resource and Referral Agencies in Massachusetts go to:  
https://www.mass.gov/service-details/child-care-resource-and-referral-agencies-ccrrs

15.		Employment at the time of Enrollment
This item is a National Outcome Measure; reporting is required by SAMHSA.
Enter one of the following codes:
1	Full-time Employment – Working 35 hours or more each week, including active duty members of the uniformed services.
2	Part-time Employment – Working fewer than 35 hours each week.
3	Unemployed-Looking for Work – Looking for work during the past 30 days or on layoff from a job.
4	Unemployed-Not Looking for Work – Not looking for work during the past 30 days.
5	Not in labor Force-Student
6	Not in labor Force-Retired
7	Not in labor Force-Disabled
8	Not in labor Force-Homemaker
9	Not in labor Force-Other
10	Not in labor Force - Incarcerated
11	Volunteer
12	Other
13	Maternity/Family Leave

If the individual has not been in the labor force for many years (such as many homeless individuals), code
as ‘Not in labor Force-Other’.

          99    Unknown
16.		Number of days worked last 30 days
Enter the number of days worked in the 30 days prior to being admitted to the program.

17.		Where do you usually live? *
This item is a National Outcome Measure, reporting is required by SAMHSA.
Check only one box.
The choices are:
•	1   House or apartment
•	2   Room/boarding or sober house
•	3   Institution
•	4   Group home/treatment – treatment is provided within the house
•	5   Shelter/Mission
•	6   On the Streets
•	7   Foster Care
•	88 Refused

*Ask where the client spent/slept most of the time over the last 12 months?*

•	If the client has been in a residential treatment program, select ‘Group Home’.
•	If the client was incarcerated, select ‘Institution’.

18.		Who do you live with?  
Check all boxes that apply.  
The choices are:
•	Alone
•	Child under 6 – whether or not your blood relation
•	Child 6-18 – whether or not your blood relation
•	Child over 18  - Only check this box if the Child Over 18 is the client’s own child
•	Spouse/Equivalent
•	Parents
•	Other Relative
•	Roommate/Friend

19.		Use of Mobility Aid
Check all boxes that apply.  
The choices are:
•	None 
•	Crutches
•	Walker
•	Manual wheelchair
•	Electric wheelchair

20.		Vision Impairment  
Enter one code from the following choices:
0	None:	Normal Vision
1	Slight:	Vision can be or is corrected with glasses/lenses
2	Moderate:  	‘Legally blind’ but having some minimal vision
3	Severe:        	No usable vision 

21.		Hearing Impairment  
Enter one code from the following choices:
0	None:	Normal hearing requiring no correction
1	Slight:	Hearing is or can be adequately corrected with amplification (e.g. hearing aid)
2	Moderate:	Hard of hearing, even with amplification
3	Severe:	Profound deafness

22.		Self-Care/ADL Impairment
Enter one code from the following choices:
0	None: 	No problem accomplishing ADL skills such as bathing, dressing and other self-care
1	Slight: 	Uses adaptive device(s) and/or takes additional time to accomplish ADL but does 	not require a 
                            personal attendant
2	Moderate: 	Needs personal attendant up to 20 hours a week for ADL
3	Severe: 	Requires personal attendant for over 20 hours a week for ADL

23.		Developmental Disability
Enter one code from the following choices:
0	None
1	Slight developmental disability
2	Moderate developmental disability
3	Severe developmental disability

If the client has received more than one level of mental health treatment listed, code the highest number.

24.		Prior Mental Health Treatment
Check only one box.
The choices are:
•	0  No prior mental health treatment history
•	1  Has received counseling for mental health problem
•	2  Has one hospitalization for mental health problem
•	3 Has more than one hospitalization for mental health problem

25.		During the last 12 months, did you take any prescription medication that was prescribed for you to
           treat a mental or emotional condition?
Check only one box.  
The choices are: 
•	1  Yes
•	2  No
•	88 Refused
•	99 Unknown

26.		Number of prior admissions to each substance addiction treatment modality
Do not count current enrollment in Question 23.

Enter one code from the following choices for each treatment modality:
0	          No prior admissions
1	     One prior admission
2	     Two prior admissions
3	     Three prior admissions
4	     Four prior admissions
5	     Five or more prior admissions
99	     Unknown

The modalities are:
•	Detox
•	Residential
•	Outpatient
•	Opioid
•	Drunk Driver
•	Section 35
•	Other
27.		Currently receiving services from a state agency
These would be state agency services, other than substance addiction, currently being received by the client. 
Check all that apply.  
The choices are:
•	None		No services from any state agency
•	DCF 		Department of Children and Families/ formerly Department of Social Services
•	DYS		Department of Youth Services
•	DMH 	Department of Mental Health / this does not pertain to all dual diagnosis clients;  clients eligible for 
                      DMH services are severely and persistently mentally ill; they would be  provided with case 
                      management services by DMH
•	DDS 		Department of Developmental Services 
•	DPH 		Department of Public Health / other than substance addiction e.g. HIV/STD, WIC
•	DTA 		Department of Transitional Assistance / cash assistance & food stamps
•	MRC		Massachusetts Rehabilitation Commission
•	MCB 	Massachusetts Commission for the Blind
•	MCDHH        Mass Commission for Deaf and Hard of Hearing
•	Other 	Other State Agency

How to code “Other” state services:  
•	A number of the State Agencies are not on this list because BSAS associates a number of Additional Client Types with services (i.e., if a client is marked as being on probation, BSAS analysts will automatically associate services from the Office of the Commissioner of Probation (OCP), if a client is checked as being on state parole, BSAS analysts will automatically associate services from the Massachusetts Parole Board (MPB).  

Coding example 
o	1: The client’s intake record indicates that s/he has MassHealth. This should not be listed as “Other. S/he is receiving state services from an agency other than MassHealth that is not on the list (such as Elder Affairs, or Veterans Services). Specify this as “Other”.  
o	

*Reminder:  Only clients currently incarcerated receive services from the Department of Corrections.  Once a person is released they no longer receive those services.

2. The client is already flagged as Parole or Probation under “Additional Client Type”. So mark “Other” only when s/he is receiving services from an agency other than MPB or OCP that is not on the list

28.		Number of arrests in the last 30 days 
This is a National Outcome Measure, reporting is required by SAMHSA.
•	Enter number of times the client was arrested in the last 30 days.  
•	Valid responses are: 0-30

Section 35 is not an arrest, it is a civil commitment

29.	 History – Substance Mis-Use / Nicotine/Tobacco / Gambling 
This item is a National Outcome Measure, reporting is required by SAMHSA.
This series is intended to elicit information about the client’s substance use, tobacco use, and gambling (RE:  gambling, please refer to regular gambling activity in place of ‘use’).  Information about the age of first use, the last time a client used a substance/tobacco/gambled, the frequency of last regular use, and the usual route of administration (NA for gambling) needs to be competed for all substances/substance categories, tobacco and gambling listed as A-Z on the history matrix.  

The choices include:

A	Alcohol	
B	Cocaine	
C	Crack	
D	Marijuana/Hashish	
E	Heroin	
F	Prescribed Opiates
Misuse/non-medical use of pharmaceutical opiates which were prescribed for the client.   (e.g. pain management)   	e.g. Oxycodone/Oxycontin
Hydrocodone/Vicodin
Methadone	
G	Non-prescribed Opiates
Non-medical use of pharmaceutical opiates which were not prescribed for the client (i.e., diversion)  	e.g. Oxycodone/Oxycontin
Hydrocodone/Vicodin
Methadone	
H	PCP	
I	Other Hallucinogens	e.g. LSD, Mescaline, Psilocybin – Street names  include Magic Mushrooms	
J	Methamphetamine	e.g. Desoxyn  - Street names include Base, Crystal, Ice, Crystal Meth		
K	Other Amphetamines	e.g. Biphetamine, Adderall, Dexedrine – Street names  include Uppers	
L	Other Stimulants	e.g. Ritalin	
M	Benzodiazepines	e.g. Valium, Xanax, Serax, Ativan, Klonopin, Librium and Tranxene –  Street names include Libs, Benzos, Vees	
N	Other Tranquillizers	e.g. Thorazine, Haldol, Clozaril, Risperdol	
O	Barbiturates	e.g. Amytal, Nembutal, Seconal, Phenobarbital	
P	Other Sedatives/Hypnotics	
Q	Inhalants	
R	Over the Counter	
S	Club Drugs	e.g. MDMA/Ecstasy, Rohypnol, GHB, Special K – Ketamine	
U	Other	
X	Nicotine/Tobacco	
Y	Gambling                                                                                                     See Q 31a  for types of gambling	
Z	K2/ Spice or Other Synthetic Marijuana	

Tip  
•	For pharmaceutical drugs that were prescribed for the client, only mark misuse (more than the recommended dosage) or non-medical use.  (Example - If a person were prescribed benzodiazepines for a mental health disorder and only took as prescribed, you would not list that on the history table.)  
•	Note:  For the safety of the client, you must have all drugs currently being taken listed in their client record.

Below are the general instructions for completing the history questions:
Have you ever used?
•	Enter ‘Y’ for Yes and ‘N’ for No.  
•	If the answer is “No”, go to the next substance.
•	If the answer is “Yes” enter the code (defined below) in the next four columns:
o	Age of First use
o	Last use
o	Frequency of last use
o	Usual route of Administration

•	Do not leave blank because doing si is a data quality issue. (was the answer  ‘No’ or was the question not asked?)
•	Data entry person needs to answer ‘Yes’ or ‘No’ before moving on – Unknown is not a choice.
•	It is acceptable to draw a downward arrow through the appropriate column.  

Age of First Use
How old was the client the first time he/she got intoxicated?  How old was the client the first time he/she used a particular drug?

Note that for alcohol the question is ‘age of first intoxication’ not ‘first use’.

Last Use
When was the last time the client used this substance? 

Enter one of the following codes:
1	12 or more months ago
2	3-11 months ago
3	1-2 months ago
4	Last 30 days
5	Used in last week

Frequency of Last Use 
If the client has stopped using this substance, code how frequently he/she used the substance previously. This question was worded this way in recognition that many clients detox either through treatment or on their own before entering particular programs and also that some clients have a complicated history of substance use. 

Enter one of the following codes:
1	Less than once a month
2	1-3 times a month
3	1-2 times a week
4	3-6 times a week
5	Daily
99   Unknown

Usual Route of Administration
Enter one of the following codes:
1	Oral
2	Smoking
3	Inhalation
4	Injection
5	Other

30a           Number of cigarettes currently smoked per day
Required if answered “Yes” to X Nicotine/Tobacco for Question 29
•	Indicate the number of cigarettes, not number of packs.
•	If client uses another type of nicotine/tobacco product, mark Zero (0) 
•	If client does not have a history of nicotine/tobacco use, skip Question 30aand go to Question 31a.

30b. 	Interest in stopping nicotine/tobacco use
Check only one box.
The choices are:
•	1   No
•	2   Yes, within 6 months
•	3   Yes, within 30 days
•	4    Does not apply (already stopped)	
•	88  Refused
•	99  Unknown 

31a.	Types of last regular gambling
Check all that apply.  For those clients with a gambling history noted in Question 26, check all types of last gambling done on a regular basis.    

The choices are:

•	Lottery -Scratch Tickets	•	Sports Betting	
•	Lottery – Keno	•	Bingo	
•	Lottery/Numbers Games	•	Dog/Horse Tracks, Jai Alai	
•	Slot Machines	•	Stock Market	
•	Casino Games	•	Internet Gambling	
•	Card Games	•		

31b. 	Have you ever thought you might have a gambling problem or been told you might?
Check only one box.  
If person does not have a gambling history, skip Questions 28a and b and go to Question 29 (Ranking of Substances). 

The choices are:
•	1  Yes
•	2  No
•	88 Refused

32.		Ranking of Substances 
•	Primary Substance                             		                  
•	Secondary Substance                                		                
•	Tertiary Substance	

Rank substances by entering corresponding letter for substances listed above in Question 29.
•	A primary substance must be marked. 
•	If there is no Secondary or Tertiary Substance of choice, leave the field blank. 
•	If a Primary, Secondary or Tertiary substance is listed in the ranking, the substance must be reported in Question 29.

If the client is unable to evaluate their preference /addiction to particular substances, the perceived severity may be determined by the clinician.  If the client is unable to evaluate, the clinician should use the following in making a determination:
•	Pattern and frequency of use
•	Degree of present or past physical, mental, social dysfunction caused by the substance
•	Degree of present or past physical or psychological dependence on the substance, regardless of the frequency of use of a specific drug.

Nicotine/Tobacco and Gambling CANNOT be marked as a primary, secondary and/or a tertiary drug.  This applies for substances A through U and Z only.
33.		Last Needle Use
Check only one box.  
The choices are:
•	0  Never
•	1  12 or more months ago
•	2  3-11 months ago
•	3  1-2 months ago
•	4  Past 30 days
•	5  Used in last week

34.	 	Have you had any overdoses in your lifetime?
The choices are:
•	1  Yes
•	2  No
34a.	How many overdoses have you had in your lifetime?
Enter the number of overdoses the client reported having in their lifetime. 
•	Question is required if answered Yes to question 34.  
•	Valid responses: 1-99    

 34b.	How many overdoses have you had in the past year?
Enter the number of overdoses the client reported having in the year prior to admission. 
•	Question is required if answered Yes to question 34.  
•	Valid responses: 0-99   

MTQAS/OTP (Opiate Treatment Program) Questions

1.  	Is your current medication-assisted treatment for withdrawal management or maintenance?    
•	Maintenance    
•	Withdrawal Management    

•	Please indicate whether the client is enrolling in medication-assisted treatment at your program for the purpose of maintenance or withdrawal management.  
•	If the client is enrolling into an extended-release injectable naltrexone treatment, please select “Maintenance” as the response to this question.

 2. 	 Are you receiving a prescription for Suboxone or Vivitrol
Check only one box. 
The choices are:
•	Yes
•	No

•	Select “Yes” if the client is enrolling in buprenorphine or naltrexone treatment at your program. 
•	Select “No” if, instead, the client is enrolling in methadone treatment, select 
•	If “No” skip to Q3.

2a		If yes, select the medication prescribed.
If “Yes” to question2, indicate the client’s prescribed medication at the time of enrollment.
•	Buprenorphine (Suboxone)            
•	Extended release injectable naltrexone (Vivitrol)

2b		Is this prescription for opioid use disorder, alcohol use disorder, or both 
Check one box.  
•	Alcohol Use Disorder
•	Opioid Use Disorder
•	Both

•	Select ‘Alcohol Use Disorder’ if the client meets criteria for an Alcohol Use Disorder and is prescribed their medication only for that disorder. 
•	Select ‘Opioid Use Disorder’ if the client meets criteria for an Opioid Use Disorder and is prescribed their medication only for that disorder.  
•	Select ‘Both’ if the client meets criteria for both an Alcohol Use Disorder and an Opioid Use Disorder and is prescribed their medication for both disorders.

3.		Current Criminal Justice Status
Check only one box. 
The choices are:
•	None
•	Probation
•	Parole
•	In Jail
•	On Bail
4.		 Number of Arrests in Lifetime
Valid entries 0-99
5.	 	Frequency of Injected Drug Use in the Past 12 Months
Check only one box. 
The choices are:
•	1   None
•	2   Less than once per month
•	3   1-3 times per month
•	4   1-2 times per week
•	5   3-6 times per week
•	6   Daily
6.		In general, how would you describe your current health?
Check only one box. 
The choices are:
•	1   Excellent
•	2   Very good
•	3   Good
•	4   Fair
•	5   Poor

7.	 	During the past 12 months, how much difficulty did you have doing your daily activities, both inside 
           and outside the home, due to physical or emotional problems?
Check only one box. 
The choices are:
•	None
•	A little bit
•	Some
•	Quite a bit
•	Unable to do daily activities

8.		During the past 12 months, how many nights were you hospitalized for physical problems?
•	Enter the number of nights spent in the hospital because of physical problems over the last 12 months.
•	Valid responses are from 0-366.

9.		During the past 12 months, how many nights were you in a detox facility?
•	Enter the number of nights spent in a detox facility over the last 12 months.
•	Valid responses are from 0-100.

10.		During the past 12 months, how many visits to an emergency room/or urgent care facility did you  
          make?
•	Enter the number of visits to either an emergency room or urgent care over the last 12 months.
•	Valid responses are from 0-100.

11.	 	In the past 12 months, how much were you distressed (bothered) by..
Check one box for each of the categories a-e

	1-- 
Not at all	2 --
 A little/slightly	3 -- 
Moderately	4 --
 A lot/extremely	
a. Nervousness or shakiness inside					
b. Suddenly being scared for no reason					
c. Feeling fearful					
d. Spells of terror or panic					
e. Feeling that something bad is going 
     to happen					

12.	  	In the past 12 months, how much were you distressed (bothered) by …
Check one box for each of the categories a-g

	1-- 
Not at all	2 --
 A little/slightly	3 -- 
Moderately	4 --
 A lot/extremely	
a.	Nervousness or shakiness inside?					
b.	Feeling blue?					
c.	Worrying too much about things?					
d.	Feeling no interest in things?					
e.	Feeling hopeless about the future?					
f.	Feeling worthless?					
g.	Feeling guilty for things that may not your fault?					

13.		Did you stay overnight somewhere for treatment of problems with your emotions, nerves, or mental 
          health?
Check only one box. 
The choices are:
•	1   Yes
•	2   No

14.	 	Did you ever get outpatient treatment or counseling for an emotional or mental health problem?
Check only one box. 
The choices are:
•	1   Yes
•	2   No

15.		In the past 12 months, did you think about suicide?
Check only one box. 

The choices are:
•	1   Yes
•	2   No

16.	 	In the past 12 months, did you attempt suicide?
Check only one box. 
The choices are:
•	1   Yes
•	2   No

17.		How supportive would you say the people closest to you are of your seeking substance addiction 
           treatment at this time?
Check only one box. 
The choices are:
•	1   Not supportive or opposed
•	2   Not very supportive
•	3   Somewhat supportive
•	4	Very supportive

18.		Would you say that none of the people, a few of the people, or most of the people you are close to are 
          currently abusing drugs?
Check only one box. 
The choices are:
•	1   None
•	2   One or a few
•	3   Most