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INTENSIVE TREATMENT SYSTEMS INITIAL CONTACT SHEET Name (Must match AHCCCS record if on AHCCCS) Is this your first time on methadone? Yes [ ] If no, how many times have you been in methadone treatment Before: Current Address City State Age No [ ] Zip Code Date of Birth Sex Status At Time Of Admission: [ ] New Client [ ] Readmission to this Program [ ] Transfer From Another Program (Complete Info Below) (Point of Contact and Phone Number) Social Security # Phone # Type Of Treatment Requested: [ ] Methadone Maintenance [ ] Grad Withdrawal [ ] Detox Ethnicity: Anglo [ ] African American [ ] Asian [ ] Hispanic [ ] Native American [ ] Other (specify) [ ] ____________________ Primary Drug Use: Special Treatment Considerations: [ ] Pregnancy [ ] Physical Disability [ ] Chronic Health Issues [ ] Chronic Pain [ ] Mental Health Issues [ ] Case Management [ ] Language/Cultural Needs [ ] SMI [ ] Gay/Lesbian Issues [ ] Other ____________ Present: __________________ Treatment Preferences: Preferred Language: ___________________ Special Cultural Needs: See Cultural Assessment Male Clinician [ Past: ________________________ ] Female Clinician [ ] Individual Counseling [ ] Group Counseling [ ] Marital Status: ____________________________ Number of Children/Age(s): _____________ Now Living With: _____________________________ Total # in household: _________________________ Education: Highest Grade Completed: ________GED: _______ Special Training/Schooling: ____________________ Vocational School: ___________________________ Other (specify) [ ] ______________________________ Currently Having Problems With? Family [ ] Marital [ ] Financial [ ] Legal [ ] Employment [ ] Other Drug Use [ ] Alcohol [ ] Medical Insurance (Primary) AHCCCS [ ] Medicare [ ] [ ] 602-582-7604 [ ] Medical Insurance (Secondary) AHCCCS [ ] Medicare [ ] [ ] 602-582-7604 [ ] If On AHCCCS: AHCCCS ID#: Employment: Employed? Yes ___ No ___ Occupation: In Case Of An Emergency Contact: Name: Phone: Seeking Employment? Address: Relationship: Advanced Directives? Yes [ ] No [ ] (If yes please specify) Yes ___ No ___ How Did You Hear About Us?: Referral Date: Intake Date: Clinical Liaison and contact number: INTENSIVE TREATMENT SYSTEMS Informed Consent and General Informed Consent Name of Client Date Name of Medical Provider Explaining Procedures Name of Medical Director Dr. Michael Ahmann D.O. I hereby authorize and give voluntary consent to Intensive Treatment Systems and its medical providers to dispense and administer methadone as an element in the treatment of my addiction to opioid drugs. The procedures to treat my condition have been explained to me, and I understand that it will involve taking the prescribed methadone at the schedule determined by the program physician, or his/her designee, in accordance with Federal and State regulations. It has been explained to me that, like all other prescription medications, methadone can be harmful if not taken as prescribed. I further understand that methadone produces dependence and, like most other medication, may produce side effects. Possible side effects, as well as alternative method of treatments and their risks and benefits have been explained to me. I understand that it is important for me to inform any medical provider who may treat me for any medical problem that I am participating in an opioid treatment program so that the provider is aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medication that might affect my opioid pharmacotherapy or my chances of successful recovery from addiction. I understand that I may withdraw voluntarily from this program and discontinue the use of the medication at any time. Should I choose this option, I understand I will be offered medically supervised withdrawal. Female Patients of Child – Bearing Age – Methadone Patients Only To the best of my knowledge, I __ am __ am not pregnant at this time. It has been explained that there is no evidence that methadone pharmacotherapy is harmful during pregnancy. If I am or become pregnant, I understand that I should tell my medical provider right away so that I can receive appropriate care and referrals. I understand that there are ways to maximize the healthy course of my pregnancy while I am on methadone pharmacotherapy. General Consent for Evaluation and/or Treatment I hereby grant permission to Intensive Treatment Systems to provide routine evaluation and treatment services as may be deemed necessary or advisable for the diagnosis and/or care of. I understand that this consent shall remain valid so long as I am enrolled in treatment at Intensive Treatment Systems or until I withdraw my consent. I understand that consent may be withheld or withdrawn at any time with no punitive action taken. I have been provided information and understand the intended outcome, nature and procedures involved in the proposed treatment, the risks including side effects (if any) as well as the risks of not proceeding and alternatives to the proposed treatment (particularly those offering less risk or other adverse effects); I understand that the information gathered in the course of my treatment at Intensive Treatment Systems is confidential. However, information may be released without my consent in cases of medical emergency involving danger to self or others, upon presentation or reasonable suspicion of physical/sexual, child or elder, abuse, abandonment or neglect, court order, insurance billing claims requirements, audit and program evaluation, upon receipt of a properly executed consent form and where otherwise legally required. I understand that my treatment will be staffed by the clinical and medical treatment team. At times, professionals in training, interns, residents and doctoral students may participate in my care and/or staffing. I understand that my treatment is individualized to my specific needs and may result in emotional discomfort the healing and recovery process. For AHCCCS TXIX funded clients: I understand that by signing the consent I am giving permission for ADHS/DBHS to access my information and records maintained by the Regional Behavioral Health Authority and/or Intensive Treatment Systems concerning provision of covered services. INTENSIVE TREATMENT SYSTEMS I certify that no guarantee or assurance has been made as to the results that may be obtained from Opioid Pharmacotherapy Treatment. With full knowledge of the potential benefits and possible risks involved, I consent to Opioid Pharmacotherapy Treatment. I have been given the opportunity to discuss with my medical practitioner the following: The diagnosis and target symptoms for the medication recommended The possible benefits/intended outcome of treatment, and as applicable procedures involved in the proposed treatment The possible risks and side effects The possible alternatives The possible results of not taking the recommended medication The possibility that my dose may need to be adjusted over time, in consultation with my medical provider My right to actively participate in my treatment by discussing medication concerns or questions with my medical provider My right to withdraw voluntary consent for medication at any time (unless the use of this medication in my treatment is required on a Court Order or on a Special Treatment Plan) ALERT!!! Deaths have been reported during initiation of methadone treatment for opioid dependence. In some cases, drug interactions with other drugs, both licit and illicit, have been suspected. However, in other cases, deaths appear to have occurred due to the respiratory or cardiac effects of methadone and too-rapid titration without appreciation for the accumulation of methadone over time. It is critical to understand the following: It will take time to stabilize on an appropriate dose level. We are required by law to start you at a safe level and increase gradually until you achieve a dose that holds you. We must be cautious with dose adjustments in the beginning of your treatment because of Methadone’s cumulative affect and individual absorption and metabolism rates. Your dose will “hold” you for longer periods of time as your tissue continues to accumulate and store methadone. A therapeutic dose level should prevent withdrawal symptoms for at least 24 hours – You should be able to 1) go to bed feeling well and wake up feeling well, 2) experience significantly reduced drug hunger or drug craving is reduced, 3) euphoric effects are blocked, and 4) you are tolerant to the sedative effects of methadone (Most commonly, stability is achieved at doses between 80 to 120 mg/day.) Self-medicating with central nervous system depressants such as secondly, Nembutal, amytal, other opiates such as Vicodin and Percocet, benzodiazepines such as Xanax, valium, and Ativan, including alcohol and some over the counter medications is extremely dangerous and could result in respiratory depression and cardiac arrest (HEART ATTACK). Keep out of reach of children Accidental overdose by a child is a medical emergency and can result in death. If a child accidentally takes methadone get emergency help right away. Do not take a higher dose of methadone or take more often than prescribed. This can lead to an overdose and possible death. I understand the medication information provided to me and by signing below, I agree to the use of this medication and treatment modality during the course of my care provided by Intensive Treatment Systems. SIGNATURE OF PATIENT DATE OF BIRTH DATE SIGNATURE OF PARENT(S) OR GUARDIAN(S) RELATIONSHIP DATE SIGNATURE OF MEDICAL PROVIDER DATE INTENSIVE TREATMENT SYSTEMS TAKE HOME APPROVAL, CHECKLIST AND EDUCATION FORM 1. CHECKLIST I understand that take home privileges are based on specific federal and state criteria and that the treatment team will make the final determination to grant take home privileges. 2. I understand that my privilege status will be reviewed periodically and may be reduced if my ability to meet the criteria changes. 3. I have been instructed on the safe handling and secure storage of my medication in the home. 4. I verify that I am able to store my medication safely and securely in my home away from children and other individuals. 5. I have been instructed and given information on the signs of methadone overdose and ways to obtain medical assistance if needed. 6. I agree to pay for my take home medication at the time of pick up. 7. I agree that I will bring my methadone doses to the clinic within 24 hours notice when called by the clinic staff for the purpose of random medication inventory. 8. I understand that diversion of methadone will result in the loss of take home medication privileges and possible involuntary termination from the program. 9. I understand that take home medication is my responsibility. Lost or stolen medication will result in the immediate reduction of take homes. Storage and Handling of Methadone Symptoms of Methadone Overdose Keep methadone out of reach of children Deep sleep Keep methadone in the child-proof container it was originally dispensed in. Slow breathing What to do Dial 911 (Emergency) for medical help, the give 1st Aid as instructed by the 911 Operator Keep methadone in a locked storage box Flushed, warm skin If a person is unconscious and is not breathing, give mouth to mouth. If no heartbeat, perform CPR. If you are unable to dial 911, take person to the nearest emergency room. Keep methadone in a cool dark place. Avoid excessive heat. Constricted pupils Take empty bottles with you to the Emergency room. Slow pulse Call clinic on-call Take your medication as directed. Call the clinic with questions regarding your takehome medications. *****************************************************MEDICAL ORDER************************************************************** ________________________________has been assessed and determined to be responsible enough to manage a Sunday Client /Holiday dose and that the benefit of having this take home outweigh the risks. __________________________________ Physician’s Assistant ___________________ Date “I have read and understand the above criteria and instructions for take home medications” _____________________________________ Client Signature ___________________________________ Staff Signature ______5/19/2016___ Date Client Initials INTENSIVE TREATMENT SYSTEMS Benzodiazepine/ETOH Screening Tool Date: _____________ Patient Name: Client ID # AHCCCS # D.OB: __________________ BZD Prescribed for what condition________________________________ BZD Prescribed: ____________________________________ BZD Dosage: ________________________________ BZD Frequency: ________________________________ BZD Prescribed by whom: ER _______ Urgent Care _________ PCP _________ Psychiatrist ______________ What other interventions and management strategies are you finding helpful for managing this condition? What other interventions and management strategies have you abandoned as ineffective? Please Indicate whether these strategies have been attempted, abandoned, or are currently utilized? Never Attempted Abandoned Now Utilize Other non-BZD medication SSRIs (Zoloft, Paxil, Prozac, Celexa, Lexapro) __ __ __ SNRIs (Effexor, Cymbalta) __ __ __ TCSs (Amytriptyline or Elavil, Pamelor Imipramine or Tofranil) __ __ __ MOA Inhibitors __ __ __ Cognitive Behavioral Counseling __ __ __ Eye Movement Desensitization/Reprocessing (EMDR) __ __ __ Somatic Experiencing Psychotherapy __ __ __ Relaxation Techniques __ __ __ Regular Exercise __ __ __ Good Sleep Hygiene __ __ __ Complementary/Alternative Medicine Strategies __ __ __ Have you ever abused BZD in the past? Have you ever used differently than prescribed? Have you ever obtained illicit BZD? Have you ever used BZD with other illicit substances Ever had withdrawal symptoms from stopping BZD Yes _____ Yes _____ Yes _____ Yes _____ Yes _____ No ______ No ______ No ______ No ______ No ______ INTENSIVE TREATMENT SYSTEMS Age over 65? Yes____ No____ History of Liver Damage? ETOH Abuse? Hepatitis? Cirrhosis? Yes____ Yes____ Yes____ Yes____ No____ No____ No____ No____ Hi Dose of BZD Xanax > 4mg/day Klonopin > 4mg/day Valium > 20mg/day Ativan > 6mg/day Yes____ Yes____ Yes____ Yes____ No____ No____ No____ No____ Drink Alcohol History of Alcohol Abuse Yes____ Yes____ No____ No____ Take any of the following medications Soma Yes____ No____ Ambien, Sonata, Lunesta, Roserem Yes____ No____ Fiorcet Yes____ No____ Seroquel or Risperdol Yes____ No____ Trazadone Yes____ No____ Other Opiates (heroin or pain medication) Yes____ No____ Beta Blockers (Metoprolol, Propranolol, Atenolol) Yes____ No____ High Doses of any medication Yes____ No____ Have there been any indicators of abuse of substances or of impairment Impairment observed in the clinic Yes____ No____ Impairment reported by others Yes____ No____ Abuse of substances on UDS Yes____ No____ Abuse encountered on Controlled Substance Log Yes____ No____ INTENSIVE TREATMENT SYSTEMS Cardiac Screening Questions: Client Name: 1. 2. 3. An abnormal EKG Long QT syndrome Cardiac Conduction Defects Date: Personal History of: Family History of: ___yes ___no ___yes ___no ___yes ___no ___yes ___no ___yes ___no ___yes ___no If yes when?_________________________________________________________ 4. Arrythmias irregular heart rate ___yes ___no ___yes ___no fast heart rate – tachycardia ___yes ___no ___yes ___no slow heart rate – bradycardia ___yes ___no ___yes ___no skipped beat ___yes ___no ___yes ___no heart palpitations ___yes ___no ___yes ___no 5. Syncope Episodes (unexplained fainting spells) ___yes ___no ___yes ___no 6. Blacking Out ___yes ___no ___yes ___no 7. Seizures ___yes ___no ___yes ___no 8. Palpitations ___yes ___no ___yes ___no 9. Dizziness ___yes ___no ___yes ___no 10. Lightheadedness ___yes ___no ___yes ___no 11. Other relevant Cardiac Disease – Structural Heart Disease – Any history of heart Disease? ___yes ___no ___yes ___no If yes, explain: _______________________________________________________ 12. Pacemakers ___yes ___no ___yes ___no 13. Members of family who have had sudden Death/Unexplained Death at a young age (< age 50)? ____________________________________________________________ Personal History of Electrolyte Disturbances 1. Have you ever had Hypokalemia? ___yes ___no 2. Have you ever had Hypomagnesemia? ___yes ___no 3. Do you take any medications that cause electrolyte disturbances? Diuretics (Lasix)? ___yes ___no Laxatives-on a regular basis? ___yes ___no Chemotherapy drugs (Cisplatin)? ___yes ___no Antifungal (Amphotericin B)? ___yes ___no Coricosteroids (Hydrocortisone)? ___yes ___no If yes, what?____________________________________________________________ Medication Use 1. List all prescription medications you are currently taking: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Client Name: _ Date: INTENSIVE TREATMENT SYSTEMS What medications have you taken now or in the past known to prolong cardiac QTC interval? ________________________________________________________________________ ________________________________________________________________________ Additional CNS Depressant Medications: 1. Do you use alcohol? ___yes ___no If yes, how often and how much? ____________________________________________________________________________________________________________ ________________________________________________________________ 2. Do you take any benzodiazepines? ___yes ___no If yes, what kind, how much, and how often? ____________________________________________________________________________________________________________ ________________________________________________________________ 3. Do you take barbiturates? ___yes ___no If yes, what kind, how much, and how often? ____________________________________________________________________________________________________________ ________________________________________________________________ Personal Use of Illicit Drugs 1. List all illicit/street drugs that you are using: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ __________________________________________ Over the Counter Medications 1. List all over the counter medications (especially ephedra) that you are taking: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ __________________________________________ Personal Use of Prescribed Narcotics 1. List all prescribed narcotics you are currently taking: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ __________________________________________ Prior history of methadone metabolism abnormalities – poor or rapid Methadone Metabolism 1. Have you ever had a peak and trough test done to assess methadone metabolism? ___yes ___no If yes, what were the resuls?______________________________________________________________________________________________________ ___________________________________ 2. Have you ever had a methadone dose above 150mg? ___yes ___no Medically Frail/Multiple Medical Conditions: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________ INTENSIVE TREATMENT SYSTEMS INTENSIVE TREATMENT SYSTEMS ____________________________________________ NORTH CLINIC 19401 N. CAVE CREEK RD. #18 PHOENIX, AZ 85024 PHONE: 602-996-0099 FAX: 602-996-1915 CARDIAC METHADONE CONSENT CLIENT NAME: CLIENT# N843 AHCCCS# A42050183 I, ___________________________ understand the following: _______That I have to watch for “racing” heartbeat, dizziness, seizures, or fainting spells and have been encouraged to go to the nearest emergency room immediately. _______That illicit drug use increases my risk for cardiac arrythmias, Torsades de Point, and death while on methadone. _______That I may need to get an EKG or appointment with cardiologist to continue on methadone or increase my methadone dosage. _______That before starting any medication I need to inform the prescribing physician that I am taking methadone which can prolong the QTc. I also need to inform my methadone clinic of any new medications that I’ve started. _______That the risk of cardiac complications from methadone increases as the dose of methadone increases. I understand that I need to discuss with the medical provider whether the benefits outweigh the risks of higher doses of methadone prior to taking higher doses of methadone. SIGNED (PATIENT) ____________________________________ DATE___________________ SIGNED (MEDICAL PROVIDER) _____________________________ DATE___________________ INTENSIVE TREATMENT SYSTEMS Alcohol Acknowledgement Date: __ Client # AHCCCS# I, ______________________________________ acknowledge the following: _____I understand that using alcohol while in methadone treatment increases the risk of intoxication or sedation and may interfere with my recovery. I understand that alcohol use while taking methadone causes respiratory depression, hypertension, and profound sedation-coma and death may result. _____I understand that due to the negative effects of alcohol use with methadone, Intensive Treatment Systems does not allow alcohol use at all for clients receiving methadone. _____I understand ITS tests for alcohol in the UDS given by clients and if I test positive for alcohol, I will be required to breathalyze daily for minimum of 30 days and my take home privileges will be reduced to “daily” for a minimum of 30 days. If I have a positive breathalyzer result, I WILL NOT RECEIVE A METHADONE DOSE AT ALL THAT DAY. If I have a positive breathalyzer result, the 30 days of daily breathalyzing and daily privileges will start over. I understand that my privilege level will be dropped by at least one level for each positive alcohol test/breathalyzer. Privilege level will be re-evaluated by the treatment team following 30 days of negative breathalyzer results. _____I understand that alcohol use when there is a history of substance abuse is not recommended. _____ I understand that starting alcohol use may result in increasing alcohol use. _____I understand that alcohol dependence can develop where the body will experience potentially life threatening withdrawal symptoms when it is abruptly discontinued. _____I understand that ongoing alcohol use will result in methadone treatment changes including dose reductions, referral to detox, and/or discharge.
