Resource Center: Printable form/checklist

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Health Center Patient Satisfaction Survey
Description: 
Provides a downloadable patient satisfaction form, that can be modified and distributed to patients. The survey assesses satisfaction with the health center and staff.
Source: 
Health Resources and Services Administration (HRSA), US Department of Health & Human Services
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Consent to Release of Information Under Title 42, Part 2, Code of Federal Regulations
Description: 
An example of the wording and structure necessary in a consent for release of information form.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Assessment and Screening Instruments
Description: 
This document provides a comprehensive collection of screening instruments and withdrawal assessments.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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DSM-IV-TR Criteria for Substance Abuse and Substance Dependence

Description: 
DSM-IV-TR Criteria for Substance Abuse and Substance Dependence

The following lists the DSM-IV-TR Criteria for Substance Abuse and Substance Dependence.

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Patient Assessment Checklist

Description: 
Before starting office-based buprenorphine treatment, the following Patient Assessment Questions should be answered for each patient. Topics addressed in these questions include: Diagnosis, Medications, Drugs/Alcohol, Psychiatric and Medical Comorbidities, Psychosocial Issues, Treatment, Patient Management, and Resources.

Diagnosis

Does the patient have a diagnosis of opioid dependence?

  • Approximately how long has the patient been dependent?
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ASAM Patient Placement Criteria

Description: 
The ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (Mee-Lee et al. 2001) lists the 5 basic levels of care available for adult substance users. These levels of care range from Early Intervention (for at-risk individuals) to Medically Managed Intensive Inpatient Treatment (for patients with severe disorders who require around-the-clock care). The Patient Placement Criteria classifies opioid maintenance therapy as a Level I treatment since it is most often conducted in outpatient settings.


According to the Patient Placement Criteria, the following 6 patient dimensions should be considered when formulating a treatment plan (Mee-Lee et al. 2001):

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DAST-10

Description: 
The Drug Abuse Screening Test, or DAST, is a self-administered test designed to provide a brief screening for drug abuse, followed by further assessment by a health care professional if necessary.

The 28-item, self-reporting Drug Abuse Screening Test (DAST) was created to screen for substance use in a clinical or treatment evaluation setting (Skinner 1982).

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TICS

Description: 
The Two-Item Conjoint Screening (TICS) scale is a brief screening tool. It screens for current substance use or dependence in a primary care population.

The Two-Item Conjoint Screening (TICS) consists of 2 questions about substance use:

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Consent Form for Buprenorphine Treatment During Pregnancy
Description: 
This consent form -- reproduced with permission from the Boston Medical Center -- can be used with your pregnant patients who want to continue taking buprenorphine during pregnancy.
Source: 
Boston Medical Center
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Buprenorphine: A Guide for Nurses
Description: 
This SAMHSA guideline provides information on buprenorphine treatment for nurses and other clinical support staff who assist with buprenorphine induction and maintenance.
Source: 
SAMHSA
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