Chronic Opiate Use

- Medical indication for use of controlled substance: _

- Analgesia: Current severity of pain: _/10

- Activity: Daily physical function: _ Psychological function: _ Objectives of treatment plan: _

- Adverse effects: _
 - Aberrant behavior: _

- PDMP Cures Run: _

- Urine Drug screen run: _

- Pt educated on naloxone and 911 Pcx. Rx for naloxone given to pt or pt already has this.15 minute counselling visit, SBIRT code Medical H0050, Medicare G0396, Commercial CPT 99408. Naloxone rx written as: Narcan nasal. Call 911 then use 1 spray in each nostril x 1 and repeat q 2-3 minutes until EMS arrives. Dispense #1

- Rx Given: _

- Next appointment: _

- ICD 10 Z79.891 assigned to chronic problem list

- COTMA signed and in the chart

- Medication list updated

Risks and benefits of use of controlled substances were discussed with the patient, including risk of habituation, withdrawal symptoms, drug-drug interactions, addiction, incomplete relief, respiratory depression, effect on sexual function, cardiac effects, and inconvenience and necessity of frequent doctor visits and obtaining prescriptions. Questions were answered.