Question | What does this mean to you? | Is this question clear? Relevant? | Would you recommend any wording changes? Recommend keeping or deleting? |
---|---|---|---|
1. Have you used opioids, sedatives, or cocaine in the past 3, 6, or 12Â months? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 1a. If yes, how often have you used them? | |||
  a. 5–6 times per week |  |  |  |
  b. 3–4 times per week |  |  |  |
  c. 2 times per week |  |  |  |
  d. 1 time per week |  |  |  |
  e. 1–3 times a month |  |  |  |
  f. Less often |  |  |  |
 1b. Did you inject any of these? | |||
  a. Yes |  |  |  |
  b. No |  |  |  |
2. Have you drank more than 4 (women) or 5 (men) standard drinks on a single occasion of 2 h or less in the past 3 months? A standard drink consists of… | |||
 c. Yes |  |  |  |
 d. No |  |  |  |
 2a. If yes, how often did you drink this amount? | |||
  a. 5–6 times per week |  |  |  |
  b. 3–4 times per week |  |  |  |
  c. 2 times per week |  |  |  |
  d. 1 time per week |  |  |  |
  e. 1–3 times a month |  |  |  |
  f. Less often |  |  |  |
3. What typical dose of opioids do you take? | Â | Â | Â |
4. Do you use any other opioids? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What opioids? |  |  |  |
5. What is your motivation for seeking the effect of opioids? | Â | Â | Â |
6. When do you typically experience symptoms of withdrawal? | Â | Â | Â |
7. Where are you typically when you experience symptoms of withdrawal? | Â | Â | Â |
8. Do you take any drugs to avoid or manage feelings of withdrawal? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What drugs? |  |  |  |
9. Where do you typically obtain opioids? | Â | Â | Â |
10. Do you use opioids with other people? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What people? |  |  |  |
11. What thoughts and beliefs make you want to purchase opioids? | Â | Â | Â |
12. Have you ever taken any actions to avoid using opioids? | Â | Â | Â |
 c. Yes |  |  |  |
 d. No |  |  |  |
 Were these actions successful? |  |  |  |
  a. Yes |  |  |  |
  b. No |  |  |  |
 Why or why not? |  |  |  |
13. Have you ever experienced problems as a result of the time you have spent to get opioids? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What kinds of problems? |  |  |  |
14. Have you ever had any negative experiences while using opioids or after? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What were they? |  |  |  |
15. How strong is your typical urge to use opioids? | |||
 a. 0—Not at all |  |  |  |
 b. 1 |  |  |  |
 c. 2 |  |  |  |
 d. 3 |  |  |  |
 e. 4 |  |  |  |
 f. 5—Moderate |  |  |  |
 g. 6 |  |  |  |
 h. 7 |  |  |  |
 i. 8 |  |  |  |
 j. 9 |  |  |  |
 k. 10—Extreme |  |  |  |
16. What types of situations or feelings cause you to want to use opioids? | Â | Â | Â |
17. Have you ever been in any physically dangerous situations while using opioids (for example like driving or operating machinery)? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 What kinds of situations? |  |  |  |
18. Do you have any known physical health problems that are affected by your opioid use? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 If so, what are they? How does your opioid use make them worse? |  |  |  |
19. Has your opioid use ever impacted your personal roles at home, work, or school? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
 If so, what impact has opioid use had on your roles? |  |  |  |
20. Has anyone close to you been affected by your opioid use? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |
21 How often does your opioid use cause problems for you at home, work, or school, or with those close to you? | |||
 a. 5–6 times per week |  |  |  |
 b. 3–4 times per week |  |  |  |
 c. 2 times per week |  |  |  |
 d. 1 time per week |  |  |  |
 e. 1–3 times a month |  |  |  |
 f. Less often |  |  |  |
22. Have you reduced or given up any activities because of your opioid use? | |||
 c. Yes |  |  |  |
 d. No |  |  |  |
 If so, what activities? |  |  |  |
22a. Do you think there’s any way to help you restart these activities? | |||
 a. Yes |  |  |  |
 b. No |  |  |  |