Withdraw Management Consult

Consult details

[Insert date of consultation.] [Insert referring physician name.] [Insert consulting physician name.] [location of consultation (e.g., ER, ICU, ward).] [patient ID.] [Indicate if note is dictated.] [Indicate if report is to be copied to another provider.]

History of present illness

[Briefly explain the circumstances of the current admission and information relevant to the reason for referral.] [Include patient-centered details: onset, duration, and progression of symptoms.] [If chronic pain or opioid therapy is relevant, address the Four A’s: Analgesia, Activities of Daily Living, Adverse effects, Aberrance.] [Include sleep and current mental health symptoms if pain/tapering is the main issue.] [Include collateral information if available.]

Substance use history

[For each substance, provide age of first use, use in the last 30 days (amount, frequency, route, date of last use), and relevant history.] - Alcohol: [Last use, pattern, history of withdrawal, history of treatment, relapse prevention, consequences, PAWSS score, collateral information.] - Opioids: [Last use, pattern, history of opioid agonist therapy (OAT), history of overdose, Narcan/THN kit, prescribed safer alternatives, highest dose, longest duration, history of treatment.] - Stimulants: [Last use, pattern, history of withdrawal, history of treatment, consequences.] - Cannabis: [Last use, pattern, history of treatment.] - Nicotine: [Age of first use, amount (pack-years), previous quit attempts, cessation medications, stage of change.] - Other substances (benzodiazepines, GHB, hallucinogens, inhalants, OTC, behavioral): [Specify substance, last use, pattern, history of withdrawal/treatment.] [Include harm reduction strategies: injection drug use (present/past/never), access to safe supplies, supervised consumption site use, OPS use, Lifeguard App, use with others, test doses, take-home naloxone, other safety strategies.]

Addiction treatment history

[Detail previous addiction treatment: detox (number and date of most recent), treatment settings (facility, dates), counseling, 12-step or SMART recovery meetings, methadone/buprenorphine (Suboxone) details (current dose, days witnessed per week, date of last dose, missed doses, prescriber, clinic, pharmacy).]

Past medical and psychiatric history

[Include past psychiatric history, past medical history, past surgeries, and hospitalizations.] [Include relevant chronic pain history if applicable.] [Include last normal menstrual period (LNMP) if relevant.]

Family history

[Include relevant family history of substance use disorders and other psychiatric diagnoses.]

Social history

[Describe current housing and duration, employment/finances, family/relationships/children, source of income, driving status, legal issues (probation/parole, pending charges, court dates, DUI), and other relevant social factors.]

Medications

[List all current medications, including in-hospital and community prescriptions, dosages, frequencies, and prescribers.] [Include medication allergies.]

Physical examination

[Document vital signs: BP, HR, RR, Temp, O2 saturation.] [General: signs of withdrawal (agitation, diaphoresis, restlessness, N/V/D, piloerection, yawning, tremor).] [Head & Neck: EENT, nodes, lacrimation/rhinorrhea, pupil diameter.] [Respiratory: IPPA.] [Cardiovascular: heart sounds, murmurs.] [GI: abdominal tenderness, obesity, masses, organomegaly (liver span).] [GU: not examined unless indicated.] [MSK: tremor, muscle atrophy.] [Skin: track marks (old/new), tattoos, trauma, stigmata of liver disease.] [Other relevant findings.]

Mental status examination

[Appearance/behaviour, speech, mood/affect, perceptual distortions, thought form/content, insight/judgment.] [HEENT: coryza, pupils (size in mm).] [Respiratory, cardiovascular, abdominal findings.] [Jaundice/icterus, ascites (yes/no).] [MSK, DERM, track marks (yes/no), other findings.]

Investigations

[List and summarize relevant laboratory and diagnostic findings.] - **Urine drug screen (UDS):** [Insert results.] - **Bloodwork:** [Cr, GFR, Na, K, Ca, Mg, PO4, GGT, AST, ALT, ALP, Tbili, Hgb, MCV, INR, platelets, albumin.] - **Toxicology:** [Insert results.] - **ECG:** [Insert findings.] [Note any abnormal results, including hematology, electrolytes, liver function tests, blood alcohol level.]

Assessment

[Summarize demographic information, reason for admission, relevant past and current medical issues.] [Provide DSM-5-based diagnoses for each substance use disorder, specifying severity (mild, moderate, severe) and status (active, early remission, sustained remission).] [If on long-term opioid therapy, include morphine equivalent daily dose (MEDD).] [Example: 'Ms. Smith is a 27-year-old woman with unstable housing and a history of recurrent abscesses and injection drug use who presents with sepsis secondary to leg cellulitis. Her assessment is consistent with severe heroin and stimulant use disorders. A nicotine use disorder was also identified.']

Plan

[Provide a clear plan for each addiction issue identified.] [Include recommendations for acute withdrawal management, stabilization, relapse prevention, pharmacological and psychosocial support options, and harm reduction.] [State if written or suggested orders, and explain any uncommon orders.] [Specify follow-up frequency and the role of the addiction medicine service.] [Discuss case with referring MD as appropriate.] [Include patient education and safety advice (e.g., driving, discharge instructions, abstinence recommendations, pharmacovigilance, slow tapering guidance, references to resources).] [Example: '1. Regarding opioid use disorder, initiate morphine 5-15 mg po q4h prn for pain/withdrawal. 2. Reassess for possible restart of methadone maintenance therapy once stable. 3. Supportive treatment for stimulant withdrawal. 4. Nicotine replacement therapy ordered. 5. On discharge, advise abstinence and follow-up with addiction counseling.']