Royal Columbian Hospital Addiction Medicine Consult

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert brief statement of reason for consultation, e.g., 'Assessment and management of substance use disorder']

Template

Name of Patient: [patient name] Date of consultation: [Insert Date] Report to be copied to: [the patient's family doctor / primary care provider or referring physician, by name, if named anywhere in the visit; if none was named, write exactly: N/A] Patient ID: [Insert Patient ID] [Mr./Ms.] [Patient Last Name] is a [Insert Age]-year-old [M/F] with a history of [Insert Relevant History] who presents with [Insert Presenting Complaint]. He/she was seen for an Addiction Medicine consultation in [Insert Location, e.g., ER, ICU] at Royal Columbian Hospital on [Insert Date]. REASON FOR REFERRAL: Patient seen for [addiction medicine assessment / methadone maintenance / withdrawal management / opioid analgesia in the context of an SUD / treatment recommendations]. HISTORY OF PRESENT ILLNESS: [Briefly explain the circumstances of the current admission and information relevant to the reason for referral. Inquire about the HPI with focused open-ended questions, i.e., patient-centered approach.] If the referral is regarding opioid analgesia or tapering for chronic non-cancer pain and long-term opioid therapy, include the Four A’s: - Analgesia (pain relief): “Tell me about your pain…” - ADLs (psychosocial functioning): “What does a typical day look like for you?” - Adverse effects (side effects) - Aberrance (addiction-related behavior: selling Rx’s, recurrent lost meds/Rx’s, chewing or IV med use, street purchase, concurrent use of illicit substance, unsanctioned escalation) If the main issue is recommendations for tapering, include: - Chronic Pain History: [Include sleep and current mental health symptoms.] SUBSTANCE USE HISTORY: - Age of first use: - Focus on use over the last 30 days including amount, frequency, route, and date of last use: - Nicotine – number of pack-years - Alcohol – beverage, non-beverage - Cannabis - Stimulants – cocaine, methamphetamines, Rx stimulants - Opioids – oxy, hydromorph, morphine, fentanyl, codeine - Benzos – Valium, Ativan, clonazepam - Hallucinogens – LSD, mushrooms, MDMA, GHB, ketamine - Inhalants – solvents, glue, paints - OTC meds – dextromethorphan, T#1, ephedrine - Behavioural – compulsive eating, working, gambling, sex, etc. ADDICTION TREATMENT HISTORY: - Detox – number of times and date of most recent - Treatment settings – name of facility, date of admission/completion - Counselling - 12-step or SMART recovery meetings - Methadone/buprenorphine (Suboxone): current dose, days witnessed per week, date of last dose, missed doses, prescriber and clinic name, pharmacy name and location if possible SOCIAL HISTORY: - Current home and for how long - Current relationship and for how long - Children - Source of income - Driving - Legal issues – probation/parole, pending charges or court dates, DUI’s - Family doctor / primary care provider name, if identified during the visit FAMILY HISTORY: - Substance use disorders and other psychiatric diagnoses in the family PAST MEDICAL HISTORY: - Past psychiatric history - Past surgeries and hospitalizations MEDICATIONS: - Medications in hospital - Community medications as per PharmaNet ALLERGIES: [Insert Allergies] PHYSICAL EXAMINATION: - BP, HR, RR, Temp, O2 sats, and mental state - General – signs of withdrawal including diaphoresis, vomiting, tremor - Head & Neck – EENT, nodes, lacrimation/rhinorrhea, pupil diameter - Respiratory – IPPA - Cardiovascular – Heart sounds, murmur - Gastrointestinal – Abdominal tenderness, obesity, masses, organomegaly (liver span) - Genitourinary – not examined - Musculoskeletal – tremor, muscle atrophy - Skin – Track marks old and new, tattoos or evidence of trauma, stigmata of liver disease LABORATORY RESULTS: - Note any abnormal results including hematology, electrolytes, LFTs - Check blood alcohol level and urine drug screen IMPRESSION: [Summarize demographic info, reason for admission, relevant past and pertinent current medical issues.] DIAGNOSES: - [List each substance use disorder, be as specific as possible: mild, moderate, severe, or other qualifier (early remission, remission, in hospitalized setting, on MMT)] - If the patient is on long-term opioid therapy, include the morphine equivalent daily dose (MEDD) RECOMMENDATIONS: - A clear plan for each addictions issue - Consider prognosis comment if guarded - State if written or suggested orders - Explain orders if uncommon issue (e.g., Suboxone) - State frequency we will follow and what role we will play (e.g., daily to manage withdrawal and provide treatment options or won’t actively follow and please call service if reassessment needed) - Discuss case with referring MD For example: 1. Regarding [substance] use disorder, the patient is currently in [state]. We suggest [treatment recommendation]. 2. We will reassess for a possible restart of [medication/therapy] once the patient is stable. 3. Treatment for [substance] withdrawal is supportive. We will follow-up to discuss treatment options. 4. [Nicotine replacement therapy has been ordered. The patient was advised… (re driving).] 5. On discharge we advise… (abstinence from drugs and alcohol and follow up with AA meetings and at SHARE/Fraserside for addiction counseling, etc.) 6. [Pharmacovigilance by the FP including treatment agreement, UDT, weekly dispensing, etc.] 7. [A slow taper of the benzodiazepine. Useful references are Deprescribing.org and the EMPOWER brochure.] 8. The addiction medicine service will follow up in [timeframe] regarding [issue] and to engage the patient regarding [treatment]. Note: Substance Use Disorder as per the DSM-5 criteria is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 2. Recurrent substance use in situations in which it is physically hazardous 3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance 4. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect b. Markedly diminished effect with continued use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.) 5. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms 6. The substance is often taken in larger amounts or over a longer period than was intended 7. There is a persistent desire or unsuccessful efforts to cut down or control substance use 8. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 9. Important social, occupational, or recreational activities are given up or reduced because of substance use 10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 11. Craving or a strong desire or urge to use a specific substance Next appointment: [Insert Date/Time or 'To be determined']