13 Intake Survey
13.1 Formatting Notes
General Formatting
• Brackets are used to describe skip and branching logic
• Response options in circles are forced choice, response options in check boxes are select all that apply
• < page break > is used to denote page breaks in STAR surveys
• Bolding is used to for emphasis or to highlight discrepancies (e.g., items with timeframes that conflict with the instruction text)
Instruction Text
• For surveys with items that are questions, instructions start with “The next set of questions ask about…”
• For surveys with items that are statements, instructions start with “Listed below are….” In addition, instructions describe how to select responses (e.g., “Select how much you agree with each statement”)
• By default, instruction text is on its own page
Survey Headers
• Survey headers are texts that are displayed on the top of every page in a survey and that specify times or qualifiers that apply to all questions (e.g., “In the past month…”)
• Ellipses end all survey headers
Item text
• Parentheses are used to list examples
• First person is only used in statements (i.e., not questions)
Response Option Defaults
Response options are in ascending order (e.g., No -> Yes, 0 -> 10, None -> Extreme)
Likert scales have 5 response options and use the following options for each type of response:
Frequency response options are: Never> Rarely> Sometimes> Most of the time> Always
Quantity response options are: Not at all> Slightly> Moderately> Considerably> Extremely
Agreement scale: Strongly Disagree > Mildly Disagree > Equally Agree and Disagree > Mildly Agree > Strongly Agree ### Daily Update (Content) Instructions
13.2 Content
13.2.1 Global Instructions
This is the first monthly update. It consists of different surveys that ask about aspects of your life and your recovery including your age, income, household, history of opioid and other drug use, drug treatment services, life events, and emotions. This first monthly update is longer than other monthly updates because it asks questions about your background. Completing this survey will take about 30 minutes and you will receive a $10 payment for completing it. Please read through all questions carefully and answer them honestly. All of your responses will be kept completely private.
? ### Demographics [Instructions:] The first set of questions asks for some general information about you.
- Which of the following best describes your religious affiliation? o Christian o Jewish o Buddhist o Muslim o Hindu o Atheist (God does not exist) o Agnostic (not sure if God exists or not) o Spiritual, but not religious o Not listed above____________
- How important is religion in your life? Not at all Mildly Moderately Considerably Extremely
- How important is spirituality in your life? Not at all Mildly Moderately Considerably Extremely
? Demographics – Monthly
[Instructions:] The next set of questions asks for some general information about your current life.
o Yes
- What is your current employment status? o Employed, working 1-39 hours per week o Employed, working 40 or more hours per week o Not employed, looking for work o Not employed, NOT looking for work o Retired o Disabled, not able to work
o Yes [If no option is selected, Relationship Assessment Scale is skipped]
[If no option is selected, Q5 is displayed]
- Who do you live with? Select all that apply. ? Spouse/significant other
? Child/grandchild
? Parent
? Other relative
? Non-relative
[If no option is selected, display Q6-Q9]
6. Uses opioids for medical reasons (uses opioids as prescribed by their doctor)? o No
o Yes
Uses opioids for non-medical reasons (uses opioids to feel intoxicated or high)?
o No
o YesUses drugs other than opioids for non-medical reasons (do not include tobacco or alcohol)? o No
o YesUses alcohol excessively (very frequently or in large amounts)? o No
o Yes
?
13.2.2 Relationship Assessment Scale
[This scale will be skipped by participants who indicate they are not in a relationship on Q3 of the monthly demographics survey and by participants who do not answer Q3] [Instructions:] The next set of questions asks you to think about your relationship with your partner in the past month.
? Lifetime Drug Use History [Instructions:] The next set of questions asks about your experience using drugs for non-medical reasons across your lifetime.
o Yes 3_1. Has a friend, relative, or anyone else ever expressed concern about your use of Alcohol? [display if Alcohol is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_1. Has your use of Alcohol led to health, social, legal or financial problems? [display if Alcohol is selected in Q1] o No
o Yes
o Yes 3_2. Has a friend, relative, or anyone else ever expressed concern about your use of Combustible tobacco products? [display if Combustible tobacco products is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_2. Has your use of Combustible tobacco products led to health, social, legal or financial problems? [display if Combustible tobacco products is selected in Q1] o No
o Yes
o Yes 3_3. Has a friend, relative, or anyone else ever expressed concern about your use of Electronic cigarettes? [display if Electronic cigarettes is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_3. Has your use of Electronic cigarettes led to health, social, legal or financial problems? [display if Electronic cigarettes is selected in Q1] o No
o Yes
o Yes 3_4. Has a friend, relative, or anyone else ever expressed concern about your use of Opioids? [display if Opioids is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_4. Has your use of Opioids led to health, social, legal or financial problems? [display if Opioids is selected in Q1] o No
o Yes
o Yes 3_5. Has a friend, relative, or anyone else ever expressed concern about your use of Cannabis? [display if Cannabis is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_5. Has your use of Cannabis led to health, social, legal or financial problems? [display if Cannabis is selected in Q1] o No
o Yes
o Yes 3_6. Has a friend, relative, or anyone else ever expressed concern about your use of Stimulants? [display if Stimulants is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_6. Has your use of Stimulants led to health, social, legal or financial problems? [display if Stimulants is selected in Q1] o No
o Yes
o Yes 3_7. Has a friend, relative, or anyone else ever expressed concern about your use of Inhalants? [display if Inhalants is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_7. Has your use of Inhalants led to health, social, legal or financial problems? [display if Inhalants is selected in Q1] o No
o Yes
o Yes 3_8. Has a friend, relative, or anyone else ever expressed concern about your use of Sedatives or sleeping pills? [display if Sedatives or sleeping pills is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_8. Has your use of Sedatives or sleeping pills led to health, social, legal or financial problems? [display if Sedatives or sleeping pills is selected in Q1] o No
o Yes
o Yes 3_9. Has a friend, relative, or anyone else ever expressed concern about your use of Hallucinogens? [display if Hallucinogens is selected in Q1] Never Once or twice Monthly Weekly Almost daily or daily 4_9. Has your use of Hallucinogens led to health, social, legal or financial problems? [display if Hallucinogens is selected in Q1] o No
o Yes
Across your lifetime… 5. Which of the following types of opioids have you ever used for non-medical reasons? Select all that apply. ? Fentanyl (Sublimaze, Actiq, apache, goodfella, TNT) ? Heroin (black tar, black pearl, black, china white, dope, white lady, smack, snow, speedball) ? Medication for opioid treatment (e.g., Suboxone, Methadone, etc.) ? Prescription opioid not for opioid treatment (OxyContin, Vicodin, Percocet, Opana)
Which of the following ways have you ever taken opioids? Select all that apply. ? Oral (swallow, chew) ? Smoke (chase) ? Sniff or snort ? Injection (IV, muscle, under skin) ? Other: ______
Have you ever overdosed while taking opioids (passed out and/or you were given Naloxone, an ambulance was called, or you were taken to a hospital)? o No o 1 time o 2 – 3 times o 4 – 5 times o More than 5 times
In the past, if all of the following opioids were available, which would you have chosen? o Fentanyl (Sublimaze, Actiq, apache, goodfella, TNT) o Heroin (black tar, black pearl, black, china white, dope, white lady, smack, snow, speedball) o Medication for opioid treatment (e.g., Suboxone, Methadone, etc.) o Prescription opioid not for opioid treatment (OxyContin, Vicodin, Percocet, Opana)
Which of the following ways have you most frequently taken opioids? o Oral (swallow, chew) o Smoke (chase) o Sniff or snort o Injection (IV, muscle, under skin) o Other _______
? ### Drug Use [Instructions:] The next set of questions asks about your experience using drugs for non-medical reasons in the past month.
o Yes
In the past month… 2_2. How often have you used Combustible tobacco products? [display if Combustible tobacco products is selected in Q1] Never Once or twice Weekly Almost daily or daily 3_2. How often have you had a strong desire or urge to use Combustible tobacco products? [display if Combustible tobacco products is selected in Q1] Never Once or twice Weekly Almost daily or daily 4_2. Have you failed to do what was normally expected of you because of your use of Combustible tobacco products? [display if Combustible tobacco products is selected in Q1] o No
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
3_8. How often have you had a strong desire or urge to use Sedatives or sleeping pills? [display if Sedatives or sleeping pills is selected in Q1] Never Once or twice Weekly Almost daily or daily 4_8. Have you failed to do what was normally expected of you because of your use of Alcohol? [display if alcohol is selected in Q1] o No
o Yes
o Yes
In the past month… 5. Which of the following types of opioids have you used? Select all that apply. [Display if opioids selected in 1] ? Fentanyl (Sublimaze, Actiq, apache, goodfella, TNT) ? Heroin (black tar, black pearl, black, china white, dope, white lady, smack, snow, speedball) ? Medication for opioid treatment (e.g., Suboxone, Methadone, etc.) ? Prescription opioid not for opioid treatment (OxyContin, Vicodin, Percocet, Opana) 6. Which of the following ways have you taken opioids? Select all that apply. [display if opioids selected in 1] ? Oral (swallow, chew) ? Smoke (chase) ? Sniff or snort ? Injection (IV, muscle, under skin) ? Other _______ 7. Have you overdosed while taking opioids (passed out and/or you were given naloxone, an ambulance was called, or you were taken to a hospital)? o No o 1 time o 2 – 3 times o 3 – 4 times o More than 5 times
Lifetime Opioid Use History
[Instructions:] The next set of questions asks about your history of using opioids (heroin, fentanyl, oxy, etc.) for non-medical reasons.
How old were you when you first began using opioids once a week for a month in a row? [Scroll bar: Under 10, 10 – 13, 14 – 17, 18 – 21, 22 – 25, 26 – 35, 36 – 45, 46 – 55, 56 – 65, Over 65]
How old were you when you first believed that your use of opioids was a problem?
[Scroll bar: Under 10, 10 – 13, 14 – 17, 18 – 21, 22 – 25, 26 – 35, 36 – 45, 46 – 55, 56 – 65, Over 65]How old were you when you first tried to quit using opioids?
[Scroll bar: Under 10, 10 – 13, 14 – 17, 18 – 21, 22 – 25, 26 – 35, 36 – 45, 46 – 55, 56 – 65, Over 65]Thinking about your use of opioids for non-medical reasons… How many times have you tried to quit using opioids?
[Scroll bar: 0 – 20+]Before you began treatment for your opioid use how many days per week did you typically use opioids?
[Scroll bar: Less than weekly, 1, 2, 3, 4, 5, 6, 7]What types of programs or services have you used in the past to help your recovery from opioids? Select all that apply. ? Detox
? Short-term residential treatment (less than 6 months) ? Outpatient treatment-individual counseling
? Outpatient treatment-group counseling
? Self-help group (Ex: Narcotics Anonymous, SMART Recovery) ? Methadone ? Buprenorphine (e.g. Bunavail, Suboxone, Zubsolv) ? Naltrexone (e.g. Vivitrol, Revia)
? Opioid Use DSM Self-Report
[Instructions:] The next set of questions asks about your use of opioids for non-medical reasons. When answering each question, think about the 12 months before you started taking medication for opioid use (e.g., Suboxone, Methadone, Buprenorphine, etc.).
- Continue to use opioids even though it often caused or worsened problems with friends, family, or other people? (e.g., arguments with friends about your use, physical fights) No Yes
- Continue to use opioids even though it often caused or worsened problems with your mental or physical health? No Yes
- Often use opioids in situations that were physically dangerous? (e.g., when driving a car, operating machinery) No Yes
In the year before you started taking medication for opioid use, did you… - Need to increase the amount of opioids you used to get high? No Yes
- Find you got much less of an effect by using the same amount of opioids as in the past? No Yes
- Experience withdrawal symptoms when you tried to cut down or stop using opioids? (e.g., nausea, vomiting, abdominal cramping, diarrhea, runny nose, watery eyes, widespread joint and muscle pain) No Yes
- Use opioids to relieve or avoid withdrawal symptoms? (e.g., nausea, vomiting, abdominal cramping, diarrhea, runny nose, watery eyes, widespread joint and muscle pain) No Yes
? ### Medication & Treatment Adherence
[Instructions:] The next set of questions asks about medications, counseling, or other forms of treatment that you have used to help your recovery from opioids in the past month.
6_1. How often did you take Buprenorphine (Bunavail, Suboxone, Zubsolv, Subutex) in the past month? [Display if “Buprenorphine” selected in Q3] Never Rarely Sometimes Most days Every day
6_1. How often did you take Methadone (Methadone Intensol, Methadose, Diskets) in the past month? [Display if “Methadone” selected in Q3] Never Rarely Sometimes Most days Every day
6_3. How often did you take Naltrexone (Revia) in the past month? [Display if “Naltrexone” selected in Q3] Never Rarely Sometimes Most days Every day
6_4. How often did you take your daily medication in the past month? [Display if “Other” selected in Q3] Never Rarely Sometimes Most days Every day
It can be hard to take medication for opioid use. What has made it hard for you? Select all that apply. ? I forget to take it ? I lose my medication ? It’s too expensive/it’s not covered under my insurance ? Trouble getting it due to a lack of reliable transportation ? I do not like how the medication makes me feel ? The side-effects are unpleasant ? I do not think I need it anymore ? I want to be able to get high ? I do not like my doctor/clinic/treatment provider ? Other___________________
In the past month… How much have you experienced side-effects while taking your medication for opioid use? [Skip if monthly or daily is not selected in Q1 or] Not at all Mildly Moderately Considerably Extremely
How effective do you think your medication for opioid use is? [Skip if monthly or daily is not selected in Q1]
Not at all Mildly Moderately Considerably Extremely
How likely are you to continue taking your medication for opioid use? [Skip if monthly or daily is not selected in Q1]
Not at all Mildly Moderately Considerably ExtremelyIn the past month… How much have you experienced opioid withdrawal symptoms? Not at all Mildly Moderately Considerably Extremely
How often have you attended self-help meetings like AA or NA? [If no options are selected, Q13 and Q14 are displayed] Never Less than weekly Weekly/near weekly Daily/near daily
14. How likely are you to continue attending your self-help meetings (NA/AA)? [Skip if never is selected for Q12]
Not at all Mildly Moderately Considerably Extremely
Not at all Mildly Moderately Considerably Extremely
17. How likely are you to continue attending your counseling sessions? [Skip if never is selected for Q15] Not at all Mildly Moderately Considerably Extremely
- Have you attended a detox program or other inpatient residential treatment for opioid use(e.g., short or long-term residential treatment, hospitalization, rehab)? No Yes
[Instructions:] The next set of questions asks about your recovery goals over the past month and in the next month.
Not at all Mildly Moderately Considerably Extremely
- How confident are you in your ability to completely avoid using opioids for non-medical reasons?
Not at all Mildly Moderately Considerably Extremely
- Do you intend to completely avoid using any other drugs (besides opioids)? o No [If selected, skip to end of survey] o Yes [If no option selected, skip to end of survey]
In the next month… - Select the drugs below that you are trying to completely avoid using. Select all that apply. ? Alcohol ? Combustible tobacco products (cigarettes, cigars, cigarillos, little cigars, pipe, hookah, bidis) ? Electronic cigarettes (e-cigarette, e-vaporizer, vape pen, e-hookah, hookah pen) ? Cannabis (marijuana, pot, grass, hash, etc.) ? Stimulants (cocaine, meth, speed, ecstasy, molly, Adderall, etc.) ? Inhalants (nitrous, glue, petrol, paint thinner, etc.) ? Sedatives or sleeping pills (Valium, Serepax, Rohypnol, etc.) ? Hallucinogens (LSD, acid, mushrooms, PCP, special K, etc.) ? Other________
Pain Catastrophizing Scale [Instructions:] Listed on the next page are thoughts and feelings you may have when you experience pain. For each statement, select the response that best describes you.
- I keep thinking about how much I want the pain to stop. Never Rarely Sometimes Often Always
?
You are more than half-way done with the first monthly update! Complete it to receive a $10 payment.
13.2.3 Brief Pain Inventory (Short Form, Modified)
[Instructions:] The next set of questions asks about any pain you have experienced in the past month.
- How bad has your pain been on average?
Not at all Mildly Moderately Considerably Extremely
- How much has pain interfered with your enjoyment of life?
Not at all Mildly Moderately Considerably Extremely
- How much has pain interfered with your general activity? Not at all Mildly Moderately Considerably Extremely
- What treatments or medications will you receive for your pain? Select all that apply. (Do not include medication you are receiving to help your opioid recovery efforts.)
? Opioid pain medications ? Non-opioid pain medications ? Surgical outpatient procedure (lidocaine injection, steroid injection, trigger point injection, medication pump, etc.) ? Surgeries (spinal fusion, discectomy, arthroscopic, etc.) ? Physical/occupational therapy
? Alternative treatments (e.g., massage, yoga, acupuncture, meditation, herbal supplements, etc.)
? No treatments or medications ? Other
13.2.4 Behavior and Symptom Identification Scale (BASIS-32)
[Instructions:] Listed on the next page are problems that some people may experience. Select the response that best describes how much difficulty you have been having in each problem area. Think about your experiences in the past month.
None at all Mild Moderate Considerable Extreme 3. Confusion, loss of memory
None at all Mild Moderate Considerable Extreme 4. Disturbing thoughts or beliefs
None at all Mild Moderate Considerable Extreme 5. Hearing voices, seeing things
None at all Mild Moderate Considerable Extreme
None at all Mild Moderate Considerable Extreme 7. Mood swings, unstable moods
None at all Mild Moderate Considerable Extreme 8. Uncontrollable, repetitive behavior (e.g., eating disorder, hand washing, hurting yourself)
None at all Mild Moderate Considerable Extreme 9. Sexual activity or preoccupation None at all Mild Moderate Considerable Extreme 10. Controlling temper, outburst of anger, violence None at all Mild Moderate Considerable Extreme
[Instructions:] Listed on the next page are statements that describe how people may feel about being distressed or upset. We are interested in how you would describe yourself. There are no right or wrong answers. For each statement, select how much you agree that the statement describes you.
- I can’t handle feeling distressed or upset. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
- My feelings of distress are so intense that they completely take over. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
- There’s nothing worse than feeling distressed or upset. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
- My feelings of distress or anger are not acceptable. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
- When I feel distressed or upset, I cannot help but concentrate on how bad I feel. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
? Perceived Stress Scale
[Instructions:] The next set of questions asks about your feelings and thoughts in the past month.
13.2.5 World Health Organization Quality of Life (WHOQOL-BREF 2)
[Instructions:] The next set of questions asks about your quality of life in the past month.
In the past month, how satisfied are you with… 1. Your overall quality of life Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 2. Your physical health Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 3. Your mental health Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 4. Your sleep Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied
1. …who you could count on to listen to you when you needed to talk?
Never Rarely Sometimes Often Always
…who gave you information to help you understand a situation?
Never Rarely Sometimes Often AlwaysHow often did you get support from someone in person (not using your phone or a computer)?
Never Rarely Sometimes Often Always
4. . …count on you to listen when they needed to talk?
Never Rarely Sometimes Often Always
…get information from you to help them understand a situation?
Never Rarely Sometimes Often AlwaysHow often did you give support to someone in person (not using your phone or a computer)? Never Rarely Sometimes Often Always
[Instructions:] Listed on the next page are a number of things people might say about themselves. We are interested in how you would describe yourself. There are no right or wrong answers. For each statement, select how much you agree that the statement describes you.
People would describe me as reckless. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I feel like I act totally on impulse. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
Even though I know better, I can’t stop making rash or careless decisions. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
Others see me as irresponsible. Strongly Disagree Mildly Disagree Agree and Disagree Equally Mildly Agree Strongly agree
I’m not good at planning ahead. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I steer clear of romantic relationships. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I’m not interested in making friends. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I don’t like to get close to people. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
It’s no big deal if I hurt other peoples’ feelings. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I rarely get enthusiastic about anything. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I crave attention. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I often have to deal with people who are less important than me. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
I use people to get what I want. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
It is easy for me to take advantage of others. Strongly disagree Mildly disagree Agree and disagree equally Mildly agree Strongly agree
Adverse Childhood Experience Questionnaire
[Instructions:] The next set of questions asks about difficult or stressful things that sometimes happen to children. Think about your entire childhood (the first 18 years of your life) as you respond.
- Did a parent or other adult in the household push, grab, slap, or throw something at you more than once? o No o Yes
- Did you live with anyone who had problems with alcohol or other drugs? o No o Yes
13.2.6 End of Survey Message
You have now completed the first monthly update! You will receive an additional $10 in your next study payment. Thank you!