Medical assessment/first visit

Transfer from Methadone Form

Description: 
This form provides a list of important considerations when determining whether a methadone patient is a candidate for transfer to buprenorphine treatment, including social, medical, and psychiatric history.

 

 Request Transfer from Methadone Maintenance to Office-Based Opioid Treatment 
Utilizing Buprenorphine 


Client Name: ______________________________
Date: ______________________________________
Admission Date: ___________________________
ID#: ________________________________________
DOB: _______________________________________

 

Transfer Criteria (please check the appropriate box and fill in as much information as possible):

[] On 30mg or less of Methadone.

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Description: 
Form for use in the clinic to support evaluation for possible opioid use disorder based on DSM-5 diagnostic criteria.
Source: 
APA
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Description: 
Buprenorphine tablets are approved for the treatment of opiate dependence. Buprenorphine treats opiate addiction by preventing symptoms of withdrawal from heroin and other opiates.
Source: 
Food and Drug Administration (FDA)
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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. If multiple issues are identified, consider whether they can be managed in your practice or if the patient requires a higher level of case, i.e. an Opioid Treatment Program or higher level.

Diagnosis

Does the patient have a diagnosis of opioid use disorder?

  • Approximately how long has the patient been dependent?
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Description: 
This patient questionnaire from the California Society of Addiction Medicine (CSAM) is useful when beginning a new patient on buprenorphine maintenance treatment.
Source: 
California Society of Addiction Medicine (CSAM)
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Description: 
This study examined the responses of older adults to the Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings.
Source: 
American Journal of Drug and Alcohol Abuse
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Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
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Patient Handouts: 
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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Physician stage in practice: 
Description: 
This form provides a list of important considerations when determining whether a methadone patient is a candidate for transfer to buprenorphine treatment, including social, medical, and psychiatric history.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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