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Client ID# Today’s Date Facility ID# Zip Code Administration
TCU DRUG SCREEN 5 – Opioid Supplement
*If the response to TCU Drug Screen 5, page 2, Q13e, Q13f, or Q13r regarding opioid use
is more than “Never,” then complete the following questions.
In the LAST 12 MONTHS –
1. What types of opioids have you used?
a. Heroin .......................................................................................................... No Yes
b. Oxycodone (Oxycontin, Percodan, Percocet) ............................................. No Yes
c. Hydrocodone (Vicodin, Lortab, Lorcet, Norco, Zohydro) .......................... No Yes
d. Morphine (Kadian, Avinza, MS Contin) ..................................................... No Yes
e. Fentanyl (Duragesic, Fentora) ..................................................................... No Yes
f. Hydromorphone (Dilaudid, Exalgo) ............................................................ No Yes
g. Methadone (Dolophine) .............................................................................. No Yes
h. Oxymorphone (Opana) ................................................................................ No Yes
i. Codeine (Tylenol/cough syrup with codeine) ............................................. No Yes
2. How many times did you inject an opioid?
Never A few times 1-3 times/month 1-5 times per week Daily
3. How many times did you take an opioid in another way (e.g., ground pills and sniffed it,
put a film in your mouth)?
Never A few times 1-3 times/month 1-5 times per week Daily
4. How many times did you take an opioid prescribed for you?
Never A few times 1-3 times/month 1-5 times per week Daily
5. How many times did you take an opioid prescribed for someone else?
Never A few times 1-3 times/month 1-5 times per week Daily
6. From whom did you get the opioids you took?
a. Medical doctor/pharmacy? ............................................................................. No Yes
b. Family member? ............................................................................................ No Yes
c. Friend? ........................................................................................................... No Yes
d. Someone else (e.g., “on the street”)? ............................................................. No Yes
7. Have you taken opioids for medical reasons? ..................................................... No Yes*
*IF YES, briefly describe the reasons:
TCU Drug Screen 5 Opioid Supplement (v.Sept17) 1 of 3
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Client ID# Today’s Date Facility ID# Zip Code Administration
8. Have you taken opioids for non-medical reasons? ............................................. No Yes*
*IF YES, briefly describe the reasons:
9. Has a doctor prescribed opioid medications for you? ....................................... No Yes*
*IF YES:
a. did you have the most recent prescription filled? .......................................... No Yes*
b. did you take all of the medications as prescribed? ........................................ No Yes*
c. did you give or sell any of your medications to someone else? ..................... No Yes*
10. Have you taken other medications or illegal drugs for medical reasons
(e.g., to treat pain)? ............................................................................................... No Yes*
*IF YES, please list:
Drug/medication: Reasons for taking:
Drug/medication: Reasons for taking:
Drug/medication: Reasons for taking:
11. Do you or someone close to you (e.g., family, friend) have access to
naloxone (Narcan) to reverse an overdose? ........................................................ No Yes
12. How many times have you EVER overdosed after taking opioids?
Never Once Twice 3 times 4 or more times
13. In the last 12 months, how many times have you overdosed after taking opioids?
Never Once* Twice* 3 times* 4 or more times*
*IF MORE THAN “NEVER,” in the last 12 months:
a. What types of opioids did you use?
1. Heroin ..................................................................................................... No Yes
2. Oxycodone (Oxycontin, Percodan, Percocet) ......................................... No Yes
3. Hydrocodone (Vicodin, Lortab, Lorcet, Norco, Zohydro) ..................... No Yes
4. Morphine (Kadian, Avinza, MS Contin) ................................................ No Yes
5. Fentanyl (Duragesic, Fentora) ................................................................ No Yes
6. Hydromorphone (Dilaudid, Exalgo) ....................................................... No Yes
7. Methadone (Dolophine) .......................................................................... No Yes
8. Oxymorphone (Opana) ........................................................................... No Yes
9. Codeine (Tylenol/cough syrup with codeine) ......................................... No Yes
TCU Drug Screen 5 Opioid Supplement (v.Sept17) 2 of 3
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Client ID# Today’s Date Facility ID# Zip Code Administration
b. How many times did you go to the hospital or emergency room
because of an overdose on opioids?
Never Once Twice 3 times 4 or more times
c. How many times were you given naloxone (Narcan) because of an overdose?
Never Once Twice 3 times 4 or more times
d. Have you received any follow-up treatment after the most recent
overdose? .............................................................................................................. No Yes
14. Have you received Medication Assisted Treatment (MAT)
in the last 12 months? ................................................................................................... No Yes
15. Are you currently receiving Medication Assisted Treatment (MAT)? ............. No Yes
*IF YES, what type?
a. Methadone (Dolophine or Methadone) ................................................... No Yes
b. Buprenorphine (Subutex, Suboxone) ...................................................... No Yes
c. Oral naltrexone (Depade, Revia) ............................................................ No Yes
d. Depot natrexone (Vivitrol) ...................................................................... No Yes
e. Other, specify: ............... No Yes
16. Have you obtained any of these medications without a prescription? ............. No Yes
17. Have you taken more of these medications than were prescribed? .................. No Yes
TCU Drug Screen 5 Opioid Supplement (v.Sept17) 3 of 3
© Copyright 2017 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.
