Opiate Addiction Worksheet
| Patient’s Name: | |||||
| Worksheet for DSM-IV criteria for diagnosis of opiate dependence | |||||
| Diagnostic Criteria* (Dependence requires meeting 3 or more criteria) |
Meets criteria
Yes No |
Notes/supporting information | |||
| (1) Tolerance, as defined by either of the following: | |||||
| (a) a need for markedly increased amounts of the substance to achieve intoxication of desired effect | |||||
| (b) markedly diminished effect with continued use of the same amount of the substance | |||||
| (2) Withdrawal, as manifested by either of the following: | |||||
| (a) the characteristic withdrawal syndrome | |||||
| (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms | |||||
| (3) The substance is often taken in larger amounts or over a longer period of time than intended | |||||
| (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use | |||||
| (5) A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects | |||||
| (6) Important social, occupational, or recreational activities are given up or reduced because of substance use | |||||
| (7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance | |||||
| Signature | Date | ||||
