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Help Me! Full Assessment of a Case Study Client Name: Roberta Assessment Date: February 4, 2024 Substance Use History Drug First Use: Yes or No Pattern of use over time? Frequency of use in past month? Date/Amount of most recent use? Prescribed Muscle relaxants, and pain medication. (Opioids) Yes There is a pattern of use overtime. The frequency of use within the past month is undisclosed. The amount of use is undisclosed. It is assumed that Roberta used within the past 24 hours as she has disclosed obtaining medication from her peers. Diagnostic Criteria Checklist Criteria Yes No Criteria Yes No Was the substance taken in larger amounts or over a longer period of time than intended? X Were important social, occupational, or recreational activities given up or reduced because of substance use? X Is there a persistent desire or unsuccessful efforts to cut down or control substance us? X Has the substance been used recurrently in physically hazardous situations? X Was a great deal of time spent in activities necessary to obtain or use the substance, or recover from the substance? X Has use continued despite knowing of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by substance use? X 1

Criteria Yes No Criteria Yes No Have they continued to use the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance use? X Has recurrent use of the substance resulted in a failure to fulfill major role obligations at work, school, or home? X Is tolerance present? X Is withdrawal present? X Is there a craving or strong desire or urge to use the substance? X DSM-5-TR Diagnosis: Severe Opioid Use Disorder DSM-5-TR Diagnostic Code: 304.00 (F11.20) Assessment Analysis 2

Basis of Diagnosis Roberta, a 16-year-old high school student, exhibits over six indicators outlined in the diagnostic checklist for opioid use disorder, suggesting a basis for diagnosis. She discloses a significant leg injury in October, for which she received prescribed pain medication and muscle relaxers. During the interview, Roberta displays restlessness, indicative of early withdrawal symptoms from opioids, implying recent usage within the past 24 hours (Jacques, 2020). Roberta mentions her inability to participate in the school swim team without pain medication due to persistent pain. Despite being unable to obtain a prescription, she resorts to purchasing pain medication from peers, resulting in academic decline and a disregard for financial consequences. These observations collectively point to clear indications of opioid misuse. Applicable Theory Roberta's reliance on opioids originated with prescribed pain medication from her doctor following a leg injury. Despite the cessation of medication from her original doctor, Roberta continues to obtain the pain medication illicitly through peers, emphasizing persistent pain and an inability to engage in sports. Expressing the desire for a prescription from another doctor due to her current inability to obtain it from the initial prescriber, Roberta exhibits clear signs of drug-seeking behavior. Her insistence on ongoing pain, despite being discontinued from the medication by a doctor, raises concerns about opioid-induced hyperalgesia, a phenomenon where prolonged opioid use may amplify pain perception (Boyaji, 2019). The combination of drug-seeking behavior, academic decline, illicit acquisition of the drug, evident withdrawal symptoms, and developing tolerance collectively indicates a severe opioid use disorder. Sociocultural Factors Roberta discloses an absence of substance use disorder (SUD) in her personal history before her involvement with opioids, and there's no indication of SUD within her parents. Despite the noticeable concerns expressed by significant adults in her life – evident through declining academic performance, a shift from being a star athlete to non-participation, and the depletion of funds from her part-time job – Roberta remains oblivious to the gravity of her opioid use. Her parents, alarmed by her behavior, strongly recommend seeking professional help, underscoring that SUD was not a pre-existing issue within the household. Despite these concerns and recommendations, Roberta continues to socially accept her ability to purchase opioids from friends. Unfazed by spending all her money on medication, she holds the belief that doctors should persist in prescribing the medication. Strikingly, she places blame on the medical professionals for her resorting to obtaining opioids from peers, showcasing a concerning lack of awareness regarding the severity of her situation and its impact on her well-being. Motivation for Change and Relapse Prevention Roberta displays a notable lack of concern for her opioid use and exhibits little interest in altering her behavior. The fact that she actively seeks a prescription and insists on the continued necessity of the medication suggests an understanding on her part of the severity of her opioid addiction. Recognizing the potential benefits of familial support and substance use disorder (SUD) treatment, I plan to initiate discussions with Roberta about the risks associated with opioid abuse. By exploring her willingness to cut down and evaluating her responses, I aim to gain insights into Roberta's readiness to address her SUD. Encouraging her to involve her parents in therapy and motivating her to explore available treatment options, I intend to collaborate with both Roberta and her family in addressing her SUD ("Fundamentals of Addiction: Motivation and Change," n.d.). 3

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