Opioid

Notes Shortcut Version

Dental DENTIX 1
Drug Check DRUGCX 1
New S8 Script request NEWS8X 1
Repeat S8 Script RPTS8X 1
Tapering Valium VALTAPERX 1
Tapering Opioid OPTAPERX 1
Follow up Tapering S4/S8 FUPTAPERX 1
Pain Review PAINX 1
6A Pain Killer Review 6AX 2
Doctors Shopping DOCSHOPX 1
Starting Opioid OPIODSTARTX 1

Drug Check - DRUGCX

Verbal consent provided by patient to check up his drug intake history

PSIS contacted, no record of patient in the Prescription Shopping list
Victorian Drug and Poison Department contacted, no S8 permit issued for the patient
Request for PBS claims information form filled up and signed by patient

Dental pain - DENTIX

Right upper gum swelling.
Booked for dentist friday already
Examination :
Right upper gum : +ve focal swelling, -ve discharge
Reason for contact:
Dental Infection
Actions:
Advised to go to dentist soon

New S8 Script request – NEWS8X

Patient request script for ^
Not known to me, not known to practice
Reason for use of medication: ^
Current pain scale : ^
Regular GP : ^
Proof of condition : ^
Reason for contact
Script
Management :
Safescript checked, ^
Other clinic/GP called, confirmed of the script
Request for PBS Claims information form printed and signed by patient
Advise to get transfer of medical record copy from other GP to get documentation of the condition

Repeat S8 Script - RPTS8X

Patient request for further script of his medication
Medication taken : ^
Reason for medication intake : ^
Noted last script done on : ^ lapses on ^
Been on the medication since ^
No S8 permit in the system
Reason for contact :
Script
Management :
Advise to combine pain medication with NSAID and Panadol
Education regarding tolerance and dependence about the medication provided

Tapering Valium – VALTAPERX

Agreed to taper valium dosage

Reasons for taper : ^
Current use : ^
Other substance use : ^
Alcohol : ^
Smoking : ^
Comorbidities : ^
Social issues : ^
Work : ^
Lives with : ^
Protective factors : ^
Does not have regular sex partners

Does not claim to have suicidal thoughts. No perceptual disturbances

No harmful thought nor act

Examination :
BP : ^ HR : ^
Wt : ^ Ht : ^ BMI : ^
Eyes : pupils isokor 4-4 mm equally reactive to lights
Arms, neck and inguinal : -ve needle tracks
Hands : -ve nicotine stain, -ve clubbing, -ve tremors

Management :
Agreed frequency of dose reduction : ^
Agreed only to get prescription from me
Agreed only to get medication from one Pharmacy : ^ on weekly basis
Patient consented for referral to ACSO
Patient advised on referral to Psychologist for further counselling
Scheduled appointment for regular review

Action :
Safescript check. No S8 permit. Alert discussed with patient
Valium Tapering Sheet agreement printed and signed by patient and me.
Letter for weekly dispensing medication to dedicated Pharmacy of Choice printed
Review in ^

Note :
10% reduction of daily dose valium every 1-2 weeks
Sign agreement

Opioid Taper - OPTAPERX

Agreed to taper opioid use

Reasons for taper : ^
Current use : ^
Other substance use : ^
Alcohol : ^
Smoking : ^
Comorbidities : ^
Social issues : ^
Work : ^
Lives with : ^
Protective factors : ^
Does not have regular sex partners

Does not claim to have suicidal thoughts. No perceptual disturbances

No harmful thought nor act

Examination :
BP : ^ HR : ^
Wt : ^ Ht : ^ BMI : ^
Eyes : pupils isokor 4-4 mm equally reactive to lights
Arms, neck and inguinal : -ve needle tracks
Hands : -ve nicotine stain, -ve clubbing, -ve tremors

Opioid Risk Tool : ^

Management :
Agreed frequency of dose reduction : ^
Agreed only to get prescription from me
Agreed only to get medication from one Pharmacy : ^ on weekly basis
Patient consented for referral to ACSO
Patient advised on referral to Psychologist for further counselling
Scheduled appointment for regular review

Action :
Safescript check. No S8 permit. Alert discussed with patient
Valium Tapering Sheet agreement printed and signed by patient and me.
Letter for weekly dispensing medication to dedicated Pharmacy of Choice printed
Review in ^

Note :
10% reduction of daily dose valium every 1-2 weeks
Sign agreement

Follow up tapering S4/S8 - FUPTAPERX

Follow up review consultation during tapering of ^
Current use ^
Current symptoms : ^
Denies other substance use
Alcohol : ^
Smoking : ^
Abberant Behaviour : ^
Work : ^
Driving : ^
Sleep : ^

No perceptual disturbances
No suicidal thought, no harmful thought nor act

Examination :
Pupils : isokor, 4-4mm equally reactive to light
BP : ^ HR : ^ , regular
Arms : -ve needle tracks
Fingers : -ve clubbing, -ve tremor, -ve nicotine stain
Skin : -ve diaphoresis

Action :
Safescript checked, no other practitioner nor pharmacy prescribing S4/S8 meds to patient
Urine drug screen ordered
Clinical Opiate Withdrawal Scale (COWS) = ^

Pain Review - PAINX

Pain feels like ^

Current meds : ^
Level of opioid : ^mg MED/day
Type of pain : nociceptive, neuropathic with psychological contribution
Activity : able to sit, standing, walking, perform ADL activities
Analgesia : average pain scale ^/10, worst pain ^/10, pain killer relieves ^% of pain
Adverse effect : no nausea, no dizziness, no constipation, no drowsiness

Abberant behaviours : has been taking meds as scheduled, has not been drinking alcohol nor taking
any other substance, no report of lost of prescription, has not escalate the doseage

Mood: no report of anxiety nor depression symptoms

Beliefs and attudes about pain : ^
Behaviours : ^
Work : ^
Driving : ^
Sleep : ^

6A Review Pain killer – 6AX

Analgesia : Pain scale : ^/10 before meds, ^/10 after meds
Adverse effects : none complained
Aberrrant behaviours : none
Activity : walking and light duties
Affect : slighly anxious due to pain
Noted last script done on ^ with ^ tablets, lapses on ^
Adherence to opioid contract with single prescriber and single designated pharmacy
Progress with functional improvement : ^

Pain Diary noted

Signs of Doctors Shopping – DOCSHOPX

New patient, recently moved to area

Walk-in, no appointment
Last minute presentation at the end of the day
Very knowledgeable about their condition and drugs requested, often requests drug by name
Previous doctor unavailable to corroborate story
Multiple ‘allergis’ or drug reactions to non-addictive medications
Carries letter from other doctors confirming treatment which appear to have dubious rationale
Exaggerated appearance of pain
Inconsistent behaviour with pain or other symptoms including variation between different
movement
Increasing behaviour when aware of being observed

Opioid Start – OPIOID1X

Agreed on trial for opioid

Goal for trial :
Pain scale : at rest, during activity
Activity :
Duration of trial :
Agreed medication to be used :
Starting dose :
Interval for review :

ORT score :

Opiod treatment agreement explained, signed and copied to patient

Explained patient

Note :
If prev history of substance abuse – in conjunction with pain specialist
If prev history of drug dependence, complex social issue, mental health – addiction spec, Psych,
APMHA
Trial for 4 weeks, after exploring other non-pharmacological and non-opioid strategies
Not to commence with another drug
Start low
Monitor every 1-2 weeks, with family member present
Advise on laxative when constipated
Aberrant drug-related behaviour checked