What are the concerns with initiating Suboxone treatment for this patient?

Please answer the following questions using the case presentation below:
What diagnostic tests would you order? Provide rationale.
What diagnosis will you give this patient? Identify and discuss 3 appropriate differentials?
Assuming MAT with Suboxone to be the treatment modality, describe the sequence of treatment for this patient.
What are the concerns with initiating Suboxone treatment for this patient?
How will you address his psychiatric care along with the MAT? What medications might you consider for any psychiatric conditions? Provide rationale.
Case Presentation
Mr. W, a 21-year-old Caucasian male, presents to the outpatient detoxification and rehabilitation facility for opioid detoxification. For the past two weeks, this patient has been using 15 bags of heroin intravenously. According to the patient, the main reason for his seeking medical attention is to avoid going to jail. The patient has a history of law violations and has been monitored by a probation officer once a week. The probation officer worked with the patient and his family to arrange the probation treatment program instead of jail. The patient voluntarily agreed to be evaluated for admission to the outpatient treatment facility.
History

Mr. W is a 21-year-old single male who was referred for treatment by his probation officer. Mr. W is currently unemployed and lives with his friends in a different location each day because his relationship with his family deteriorated due to addiction; he is no longer welcome in the family home. According to Mr. W, he is not homeless. “I always find a place to crash for a night.” Mr. W states that he has been using marijuana from age 15, but it is not his drug of choice any longer. He was introduced to heroin by his best friend about five years ago during very stressful times in his undergraduate school. He states that his parents and two sisters are aware of his addiction problems and do not support him at all. However, his grandmother understands him more than anyone and supports him financially to prevent him from stealing. Mr. W states that, “If you do not admit me today, I will go and get high, and I do not care what happens to me after.”
History of Present Illness
Mr. W presents for opioid detoxification and rehabilitation. He has no past medical history or any hospitalizations for medical conditions. However, he states that he was found unconscious by his mother in August 2016 and was hospitalized due to a heroin overdose. He left the hospital against medical advice after two days of admission. He denies any history of head injury, trauma, asthma, hypertension, diabetes mellitus, or seizures. He is not on any prescribed medications. In addition, he denies any history of food, drug, or latex allergies. Mr. W also denies any surgical history.
Psychiatric History
Mr. W reports that he has struggled with severe anxiety and mild depression from an early adolescent age. He stated that he cannot remember the time when he was free of anxiety without using drugs. According to the patient, he was never hospitalized for anxiety or depression. However, he states that he has had suicidal ideations in the past, but not suicidal attempts. He denies any history of self-inflicted injuries. He has been prescribed benzodiazepine (Xanax) a medication for anxiety and Seroquel, antipsychotic (an atypical type) for depression, but stopped taking both medications two years ago. “I am not crazy and don’t want to be hooked on it.” Currently he is not under either a psychologist’s or psychiatrist’s care and does not take any psychiatric medication.
Review of Systems
Mr. W reports that he was not feeling well, because he took his last bag of heroin at five in the morning. He denied recent visual changes, eye pain, discharge, or inflammation. Denies a history of shortness of breath, wheezing, chest pain, or chest palpitations or arrhythmia. Mr. W states that he is very nauseous and had diarrhea in the morning but denies abdominal pain. Mr. W is very restless, states that he has pain in his back, rated five out of 10 and just feels uncomfortable sitting in the chair although he denies a history of joint disease. Denies skin rash, moles, or changes in skin pigmentation. Denies any urinary incontinence, urgency, or frequency. However, he states that his appetite has decreased during the past year and has been constipated for the past week. Denies use of any over-the-counter medications for his constipation.
Physical Exam
Well-developed and nourished, slightly disheveled White male. Patient is alert and oriented to person, place, time, and situation. Easily irritable, angry, and very talkative. Able to make needs clear; rapid speech.
Vital signs are: BP 130/88 (left arm, sitting position),HR 104, RR 22, Temp. 98.8 Fahrenheit.
Normocephalic, atraumatic, short hair and symmetric flushed face.
Eyes: Pupils are constricted bilateral to 1 mm, round, reactive to light and accommodation, sclera is red and teary.
Ears with normal ear canal and tympanic membrane.
Runny nose no erythema of nostrils and normal septum.
Dry oral mucous membranes, poor dentations, and missing back tooth.
Neck supple with midline trachea and no lymphadenopathy or jugular vein distention.
Heart rate is regular but mild tachycardia (104), no murmurs, rubs or gallops, bilateral dorsalis pedis pulses 2+.
Anterior and posterior lungs sounds are clear to auscultation bilateral, no wheezing, crackles or rhonchi.
Bilateral upper extremities with multiple tattoos and fresh needle track marks in the antecubital area and popliteal space in the lower extremities. Bilateral hand tremors with extended arms, no edema noted on upper or lower extremities. Bilateral feet with dry, cracking and peeling skin, with evidence of scratching. Bilateral toenails and fingernails within normal limits, no cyanosis or clubbing of nails noted.

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