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Assessment and Treatment Planning for Cocaine-Abusing Methadone-Maintained Patients
Treatment Improvement Protocol (TIP) Series10

Appendix I - Internal Trigger Questionnaire and External Trigger Questionnaire

Internal Trigger Questionnaire * (Sample Questionnaire)

During the early and middle stages of cocaine addiction there are often certain feelings or emotions that trigger the brain to think about using cocaine. Read the following list of emotions and indicate which of them can trigger (or used to trigger) cocaine cravings for you:
_____ Afraid	_____ Exhausted	_____ Jealous
_____ Angry	_____ Frustrated	_____ Lonely
_____ Confident	_____ Guilty	_____ Neglected
_____ Criticized	_____ Happy	_____ Nervous
_____ Depressed	_____ Inadequate	_____ Passionate
_____ Embarrassed	_____	_____ Pressured
_____ Excited	_____ Irritated	_____ Relaxed
		_____ Sad
I thought about using cocaine when I felt: Circle the above emotional states or feelings that have triggered your cocaine use recently. Has your cocaine use in recent weeks/months been ________ 1. Primarily tied to emotional conditions ________ 2. Routine and automatic without much emotional triggering Are there any times in the recent past in which you were attempting to stay drug free and a specific change in your mood clearly resulted in cocaine use? (For example, you got in a fight with someone and went to use in response to getting angry.) Yes__________ No__________ If yes, describe:
* Used with permission from Matrix Institute on Addictions. Copyright by Matrix Institute on Addictions.

External Trigger Questionnaire * (Sample Questionnaire)

Place a check mark next to activities or situations in which you frequently used cocaine. Place a zero (0) next to activities or situations in which you never have used drugs.
_____ Home alone	_____ Before a date	_____ After payday
_____ Home with friends	_____ During a date	_____ Before going out to dinner
_____ Friend's home	_____ Before sexual activities	_____ Before breakfast
_____ Parties	_____ During sexual activities	_____ At lunch break
_____ Sporting event	_____ After sexual activities	_____ While at dinner
_____ Movies	_____ Before work	_____ After work
_____ Bars/Clubs	_____ When carrying money	_____ After passing a particular freeway exit
_____ Beach	_____ Ater going past dealer's residence	_____ School
_____ Concerts	_____ With particular people	_____ Driving
List any other settings or activities where you frequently use drugs. List activities or situations in which you would not use drugs. List people you could be with and not use drugs.
* Used with permission from Matrix Institute on Addictions. Copyright ? by Matrix Institute on Addictions.

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