Axis House - Admission Checklist/Referral with Inclusion/Exclusion Criteria: Updated Aug 2018

Mental Health & Substance Use Axis House

Castlegar location Phone: 778 460 1901

Fax: 778 460 1902

Axis House – Admission Checklist/Referral

Referral Source: ______________________________ PHN: _____________________________

Patient Name: ______________________________ DOB: _____________________________

Patient phone number: ______________________________ Allergies: ____________________________

** Please fill out Plan G and send copy with information** Plan G initiated 1. Safety:

Inclusion / Exclusion criteria on back side reviewed.

Urine Drug Screen complete (all referrals)

2. Substance Withdrawal Plan (see attached pre-printed orders): ALCOHOL

Bloodwork completed (see orders)

OPIATES

STIMULANTS

3. Assessment of Previous Withdrawal (indicate only if applicable): History of Seizures History of Delirium tremens

4. Medical Assessment Completed: Medically stable

Current medical conditions if any: ________________________________________________________________________________________________________

5. Psychiatric Assessment Completed: Psychiatrically stable. Current psychiatric diagnosis if any: _____________________________________

6. Current Medications: Prescription required for all medications during stay, please prescribe these on Physician’s orders

7. Housing: Withdrawal Management Program Staff with work with the Individual to link to resources in the community to support finding suitable housing if needed. If homeless the client is aware he/she may be discharged back to a homeless state.

8. Handout for clients: “What to Bring” and “Occupancy Guidelines” given to client for review.

Fax copies of prescription and protocols to Axis House – 778 460 1902 Date: ________________________ PHYSICIAN’S NAME: __________________________ PHYSICIAN’S SIGNATURE: ________________________________ As referring Physician, I am prepared to follow the patient while in the program. Contact number: __________________________ Axis on-call Physician to follow the patient while in the program.

Axis House - Admission Checklist/Referral with Inclusion/Exclusion Criteria: Updated Aug 2018

.

Axis House Inclusion / Exclusion Criteria INCLUSION:

Client doesn’t need to be hospitalized.

o No significant health risks, such as any history of previous uncontrolled seizures, no complicated withdrawal predicted.

o No physical or psychiatric symptoms (client is currently stabilized).

Client is independent with daily activities, able to mobilize, and willing to cooperate with treatment.

Client has been assessed by physician and medications ordered as needed. EXCLUSION:

Complicated withdrawal is predicted.

Has experienced difficult withdrawal requiring hospitalization in past.

Recent head injury or loss of consciousness (unrelated to effects of intoxication).

Serious medical conditions/acute psychosis.

Unable to climb minimum of 3 stairs, high fall risk, poor mobility.

Unable to do ADLs including feeding, toileting and showering self.

Current severe nutritional disorder that requires medical care (e.g. IV care).

Clients who are certified under the Mental Health Act.

Recent violent or physically aggressive behavior.

GENERAL INFO:

. Physician support is required. If admitting physician is unable to provide ongoing support, please designate Axis on-call

physician to assume care. Admissions and discharges are at the discretion of the Axis House RN.

June 2018

WITHDRAWAL Protocol for Adults

SYMPTOM MANAGEMENT and OPIATE AGONIST THERAPY Orders

MEDICATIONS: Multivitamin ONE dose PO / daily

Folic Acid 5mg PO daily

DimenhyDRINATE 25 to 50 mg PO /IM / Q4-6H PRN nausea

Acetaminophen 325-650mg PO Q4-6H PRN pain/headache (max. of 4g/24 hrs)

Ibuprofen 200-400mg PO QID PRN for pain/headache

Ranitidine 150mg BID PRN for heartburn

Calcium Carbonate 500-1000mg PO chewable Q4H PRN heartburn

Sennoside 8.6mg Tabs -2 Tabs BID PRN for constipation

Loperamide 2-4 mg PO PRN for diarrhea

Calcium 333mg/Magnesium 1-2 tabs po prn for mild muscle cramping (max. of 3 tabs/24hr)

OPIATE AGONIST THERAPY (for Buprenorphine/Naloxone Induction, please complete page 2)

BC Centre on Substance Use/Ministry of Health Guideline for the clinical management of Opioid use disorders states: Withdrawal Management

alone is not an effective treatment for opioid use disorder, and offering this as a standalone option to patients is neither sufficient nor appropriate.

Please check to order: □ Clonidine 0.1mg PO TID PRN for symptoms of withdrawal (hold if diastolic BP

June 2018

WITHDRAWAL Protocol for Adults

SUBOXONE (Buprenorphine/Naloxone) Induction Orders

NURSING CONSIDERATIONS:

DELAY INDUCTION UNTIL CLIENT HAS ABSTAINED FROM OPIATE USE FOR A MINIMUM OF 12-24 HOURS In the interim, use Clonidine (see below) as indicated

Monitor withdrawal symptoms using the Clinical Opiate Withdrawal Scale (COWS) Assess client using COWS prior to each and every dose, and 1 hour after administration of each and every dose Each administration must be witnessed directly by staff Client must be advised to refrain from eating, drinking, speaking, smoking for 10mins while sublingual tablets dissolve Staff to remain in client’s presence for 10mins after administration of each dose

Day 1

Administer initial dose of 4mg/1mg Buprenorphrine/Naloxone SL

If withdrawal symptoms are not adequately relieved after 1-3 hours: administer additional 2mg/0.5mg Buprenorphrine/Naloxone SL, reassess in another 1 hour

Repeat hourly until withdrawal symptoms are adequately relieved or to a max of 12mg/3mg on Day 1.

Day 2

Ascertain whether Day 1 dose was sufficient to adequately relieve withdrawal symptoms o If withdrawal symptoms were adequately relieved on Day 1: administer the total dose received on Day 1 (dose will be

between 4mg/1mg - 12mg/3mg Burprenorphrine/Naloxone SL) o If withdrawal symptoms were NOT adequately relieved on Day 1: administer 16mg/4mg Buprenorphine/Naloxone SL

Day 3

Ascertain whether Day 2 dose was sufficient to adequately relieve withdrawal symptoms o If withdrawal symptoms were adequately relieved on Day 2: administer that dose again (dose will be between 4mg/1mg

- 16mg/4mg Burprenorphrine/Naloxone SL) o If withdrawal symptoms were NOT adequately relieved on Day 2: administer 20mg/5mg Buprenorphine/Naloxone SL

Day 4

Ascertain whether Day 3 dose was sufficient to adequately relieve withdrawal symptoms o If withdrawal symptoms were adequately relieved on Day 2: administer that dose again (dose will be between 4mg/1mg

- 20mg/5mg Burprenorphrine/Naloxone SL) o If withdrawal symptoms were NOT adequately relieved on Day 3: administer 24mg/6mg Buprenorphine/Naloxone SL

Maintenance dose is achieved when client is no longer experiencing uncomfortable symptoms of Opiate withdrawal. It may be reached on any of the induction days thus induction may take LESS than four days. This maintenance dose will be the client’s daily dose moving forward unless otherwise indicated.

□ Clonidine Option (please check to order):

Clonidine 0.1mg PO TID PRN for symptoms of withdrawal PRIOR to Day 1 induction OR for precipitated withdrawal symptoms only

(withhold dose if diastolic BP less than 60 mm Hg)

o Avoid use for 8hrs prior to first Buprenorphine/Naloxone dose as it may mask withdrawal symptoms and interfere with

successful titration

Prescribers must agree to (or assign a designate) to continue outpatient Opiate Agonist Therapy at conclusion of inpatient therapy. TRIPLICATE PRESCRIPTION MUST ACCOMPANY THIS ORDER to Axis House by FAX, and mail original to Simply Shoppers Pharmacy, #117 1983 Columbia Ave., Castlegar BC, V1N 2W8 Physician/NP signature: Date/Time:

Safety Bulletin: Avoid the use of withdrawal management as a standalone treatment for opioid use disorder Recommendation: Withdrawal management alone is not an effective treatment for opioid use disorder, and offering this as a standalone option to patients is neither sufficient nor appropriate. Care providers should clearly communicate to patients the risks of withdrawal management as a standalone strategy and encourage a period of opioid agonist therapy or a slower outpatient taper (e.g., > 3 months) with methadone or buprenorphine/naloxone. In the event that patients choose to proceed with withdrawal management without follow-up treatment, providers may consider using an informed consent form or waiver to document that this decision has been made against medical advice. A sample waiver is appended to this document. Risks of Detox: Acute withdrawal management (also known as “detox”) is an intervention aimed at reducing health harms, such as withdrawal seizures, associated with substance use cessation. However, as a standalone intervention, withdrawal management does not constitute “addiction treatment,” and can be associated with harm, especially in the context of opioid use disorder. What the Research Says: Research has shown that, when offered as an isolated intervention for opioid use disorder, inpatient withdrawal management may leave patients particularly vulnerable to the following serious health harms:

Nearly universal rates of relapse to opioid use – Abrupt (e.g., < 1 week) taper off of opioids results in the vast majority of individuals returning to opioid use.1

Elevated risk of overdose – Individuals who relapse following withdrawal management are at increased risk of overdose as a result of the rapid loss of tolerance to opioids.2

Elevated risk of infection – Studies have shown that, in comparison to offering nothing, persons who inject drugs who undergo withdrawal management are more likely to contract HIV and Hepatitis C, likely as a result of high risk behaviours upon relapse.3,4

Opioid Agonist Therapy: In British Columbia, inpatient opioid withdrawal programs are generally rapid (e.g., 1 week). When risk of relapse presents upon discharge, continuity of care can be particularly challenging as waitlists and other programmatic barriers often prevent immediate readmission to inpatient withdrawal or other safe environments. Instead of rapid inpatient opioid tapers, studies suggest that opioid agonist therapy (OAT) using buprenorphine/naloxone or methadone is more effective in terms of patient retention and satisfaction, sustained abstinence from opioid use, and decreased risk of morbidity and mortality related to overdose, HIV and HCV transmission.3-6 Outpatient Withdrawal Management: For patients who wish to discontinue opioid use without long-term OAT, a slow (e.g., > 3 month) outpatient taper with buprenorphine/naloxone or methadone should be an available option to address continuity of care issues associated with discharge from inpatient care, and ensure ongoing close follow up with an outpatient care provider should longer term OAT be necessary. Slower (e.g., up to one year) tapers have been associated with improved rates of abstinence and successful discontinuation of OAT.7 Additionally, referral to an evidence-based residential treatment or an intensive outpatient addiction program should be considered for all individuals with opioid use disorder who decline long-term OAT.

Specific Populations: Although inpatient, rather than outpatient, withdrawal management has traditionally been recommended for specific patient populations, such as individuals with concurrent mental health conditions, these patients may be particularly vulnerable to harm from short term (e.g. one week) inpatient opioid withdrawal management. For these patients, as with patients without serious comorbidities, outpatient community care involving OAT or slow tapers off of opioids through community-based withdrawal management involving ongoing addiction treatment should be prioritized. Using Inpatient Withdrawal Management Effectively: Inpatient withdrawal management can be an important first point of contact and act as a bridge to ongoing addiction treatment. Additionally, inpatient facilities can provide more intensive monitoring, support and symptom management, and may be appropriate care settings for challenging OAT inductions or transitions between treatments (e.g., methadone to buprenorphine/naloxone). For additional support, physicians should consider contacting the Rapid Access to Consultative Expertise (RACE) telemedicine addiction support at 604-696-2131 (raceconnect.ca). For further reading, please refer to the BCCSU/Ministry of Health Guideline for the Clinical Management of Opioid Use Disorder at http://www.bccsu.ca/wp-content/uploads/2017/02/BC-OUD-Guidelines_FINAL.pdf.

References

1. Wright NM, Sheard L, Adams CE, et al. Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a

randomised controlled trial. The British journal of general practice : the journal of the Royal College of General Practitioners. 2011;61(593):e772-780.

2. Strang J, McCambridge J, Best D, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ. 2003;326(7396):959-960.

3. MacArthur GJ, Minozzi S, Martin N, et al. Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. BMJ. 2012;345:e5945.

4. MacArthur GJ, van Velzen E, Palmateer N, et al. Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness. International Journal of Drug Policy. 2014;25(1):34-52.

5. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2:CD002207.

6. Esmaeili HR, Ziaddinni H, Nikravesh MR, Baneshi MR, Nakhaee N. Outcome evaluation of the opioid agonist maintenance treatment in Iran. Drug Alcohol Rev. 2014;33(2):186-193.

7. Nosyk B, Sun H, Evans E, et al. Defining dosing pattern characteristics of successful tapers following methadone maintenance treatment: results from a population-based retrospective cohort study. Addiction (Abingdon, England). 2012;107(9):1621-1629.

http://www.bccsu.ca/wp-content/uploads/2017/02/BC-OUD-Guidelines_FINAL.pdf

CONSENT AND RELEASE FORM FOR WITHDRAWAL MANAGEMENT SERVICES Patient Label: By checking the boxes below and signing this consent form, I confirm that I understand and/or agree with the following statements: I understand that I have been diagnosed with an Opioid Use Disorder.

I understand that, according to current medical evidence, the safest and greatest chance of

recovery from opioid use disorder can be achieved by starting opioid agonist treatment with buprenorphine/naloxone or methadone (first-line agents). The recommended duration of opioid agonist treatment varies depending on individual needs and circumstances.

I understand that if I choose to proceed with withdrawal management (also known as ‘detox’)

without follow-up care, I have a high risk of relapse, and a high risk of overdose due to decreased tolerance to opioids. Overdose can cause severe harms including brain damage, coma, and death.

I understand that withdrawal management alone is against medical advice. I have been given sufficient time and opportunity to ask questions about the information above,

and have received satisfactory clarification and advice. I fully release and discharge the physician and staff from any responsibility or liability for any losses,

damages, or injuries I may suffer as a result of my decision not to go on opioid agonist treatment. I consent to undergo withdrawal management services to be provided by the physician and care

team, and have opted not to pursue follow-up care at this time.

Client Signature Date

Physician, Nurse or Staff Name and Signature Date

affix here

Mental Health Substance Use Centres or Child and Youth Mental Health Service Centres: Fax this form to Health Insurance BC at 250 405-3896.

Select the most applicable options.

I certify that: a. The patient has been hospitalized for a psychiatric condition.

b. Without prescribed medication, the patient is likely to be hospitalized for a psychiatric condition.

c. Without prescribed medication, the patient or another person is likely to suffer serious physical or psychological harm, or economic loss.

PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN G

A. TO BE SIGNED BY THE APPLICANT (PLEASE SEE INSTRUCTIONS ON REVERSE)

HLTH 3497 Rev. 2016/12/21 PAGE 1

NOTE: FORMS SUBMITTED BY UNAUTHORIZED PERSONS OR WITH INCOMPLETE MANDATORY FIELDS WILL BE RETURNED. If applicant contact information is not provided, the applicant cannot be notified of coverage expiration.For more information on Plan G or to access this form online, visit www.gov.bc.ca/pharmacareprescribers.

If you have received this fax in error, please write “MISDIRECTED” across the front of the form and fax it back to the sender.

Name - mandatory Phone Number

Address Postal Code

Personal Health Number (PHN) - mandatory Birthdate (YYYY / MM / DD)

Personal information on this form is collected under the authority of section 22 of the Pharmaceutical Services Act for the operations of PharmaCare’s Psychiatric Medications Drug Plan (Plan G). The personal information will be used to support the applicant to be a Plan G beneficiary. Personal information will be released to PharmaCare and to a Mental Health Substance Use Centre for the provision of drug benefits. If you have any questions about the collection of personal information on this form, contact your local health authority or Health Insurance BC (HIBC)–from the Lower Mainland: 604 683-7151 or, from elsewhere in B.C., toll free at 1 800 663-7100. This information will be used and disclosed in accordance with the Freedom of Information and Protection of Privacy Act and the Pharmaceutical Services Act.

Applicant Signature - mandatory Date Signed

B. PRACTITIONER ONLY – TO BE SIGNED BY THE PRESCRIBING PRACTITIONER (PHYSICIAN OR NURSE PRACTITIONER)

Name of Prescribing Physician or Nurse Practitioner

Physician/Nurse Practitioner: Fax this form to your local Mental Health Substance Use Centre, Child and Youth Mental Health Service Centre, OR the mental health contact at your local health authority to complete Section C for approval. Do NOT fax directly to Health Insurance BC.

Phone Number Fax Number

Signature of Prescribing Physician or Nurse Practitioner - mandatory

C. MENTAL HEALTH SUBSTANCE USE CENTRE / HEALTH AUTHORITY ONLY – APPROVAL

1 year Less than 1 year

Authorization Expiration

Centre Name - mandatory

Name of Director or Designate

Date Signed

D. HEALTH INSURANCE BC PROCESSING

I declare that the cost of prescribed psychiatric medication is a significant barrier to my taking my medication. I have no other financial coverage, and I believe I qualify for Medical Services Plan Premium Assistance ($42,000 family adjusted net income plus $3,000 per dependent).

Practitioner College ID Number - mandatory

Site Location ID

Signature of Director or Designate - mandatory

Phone Number Fax Number

Date SignedExpiry Date (YYYY / MM / DD)This authorization will expire in:

PSYCHIATRIC MEDICATION COVERAGEAPPLICATION FOR PHARMACARE PLAN G

HLTH 3497 PAGE 2

Instructions for Authorized Persons completing this form:

If the applicant is unable to sign the form:1. Ensure all required fields are complete.

2. Have the applicant verbally declare that they meet the Plan G eligibility requirements but are unable to sign the Plan G application.

3. Write “Verbal Declaration” in the Applicant Signature box of the Plan G application.

4. Sign your name as a witness in the Applicant Signature box beside the words “Verbal Declaration.”

If the applicant is unwilling to sign the form:1. Ensure all required fields are complete.

2. Have a person who is legally empowered* to sign the application on behalf of the applicant sign their name in the Applicant Signature box of the Plan G application.

3. Indicate in writing, beside their signature, the legal authority that empowers them to make the declaration on the applicant’s behalf.

OR

*A person legally empowered to sign must be one of the following: a committee appointed under the Patients Property Act, a person acting under a power of attorney, a litigation guardian, or a representative acting under a representation agreement.

PLAN G

Plan G coverage is provided for a set period not exceeding one year. When this period expires, the practitioner may re-apply for continued coverage.

Plan G coverage may be extended to new residents who have not yet qualified for the B.C. Medical Services Plan (MSP). In this case, the practitioner must submit a written request with the application for Plan G coverage, detailing the patient’s compelling need for exceptional coverage. If approved, Plan G coverage will be provided for a period of three months, during which time the patient must apply for MSP.

Please give to client to review before admission.

WHAT TO BRING

o Health Care Card and Extended Health ID

o Comfortable clothing sufficient for 4 days

o Appropriate sleepwear including socks or slippers for your feet

o Long distance phone card if you want to call long distance

o Toiletries: toothbrush, toothpaste, hair products, deodorant, hair dryer, shaving supplies, lotion, (NO

PRODUCTS CONTAINING ALCOHOL OR AEROSOLS WILL BE ALLOWED)

o If you smoke please bring enough cigarettes (in unopened packages) for 5 days. We do not allow opened

packages of cigarettes brought in, chewing tobacco, hand rolled cigarettes, flavoured cigarettes, cigars.

Nicorette gum or nicotine patches are acceptable but must be brought into the program new/ unopened.

E-juice brought into the program must be sealed and unopened.

WHAT NOT TO BRING

The following list contains items that clients are not permitted to have in their possession. If these items are

brought into the program, they will be kept locked up until you complete the program.

o No outside food or drinks, including water, candy, or chewing gum.

o No cell phones, computers, tablets, music equipment, televisions, i-pods, mp3 players, clock radios,

cameras

o No expensive jewellery or excessive cash.

o No hair dye, bleaching products, nail polish and remover

o No perfume, cologne, aftershave, strong perfumed lotions and bath products.

o No alcohol or drugs

o No pictures or photos that depict alcohol/ drug usage, violence or sex

o No weapons of any kind, including scissors

o No clothing that depicts alcohol, drugs, sex, or violence.

o No straight razors and/ or razor blades

o No pillows, blankets, sheets, towels, or stuffed toys

o No zippos, lighter fluid or butane,

o No E-juice that is alcohol or cannabis flavoured.

o No short shorts, halter tops, shirts that show your midriff

Page 1 of 1

Please give to client to review before admission.

OCCUPANCY GUIDELINES

1. Visitors are not allowed at the withdrawal management program.

2. All alcohol, drugs, and paraphernalia found in the possession of a client will be confiscated and destroyed. Use of

alcohol or other drugs at the program may result in termination of services.

3. Staff reserves the right to conduct room searches at any time there may be a concern for the safety of clients and staff.

4. All products containing alcohol (e.g., mouthwash, hair spray, cologne, after shave, etc.) will be confiscated at time of

admission and returned at time of discharge.

5. All items considered to be a threat to client safety (e.g., razors, knives, and scissor’s) will be confiscated at time of

admission and returned at time of discharge. Clients may use safety razors and other hygiene-related “sharps” only with

permission.

6. Cell phones, computers, tablets, CD’s, DVD, I-pods, MP3 players and other devices are not allowed to remain in a

client’s possession while at the withdrawal management program. These items will be stored with other client valuables

and returned at time of discharge.

7. Smoking: Cigarettes, E- Vapes, cigars, lighters, matches, etc. will be confiscated at time of admission and stored in the

staff office. Smoking is restricted to designated outdoor areas. Clients will be allowed to go outside to smoke every

two hours when staff is available to supervise. Smoking indoors is strictly prohibited and may result in termination of

services. Clients taking medications that are incompatible with nicotine will not be allowed to smoke while in the

withdrawal program. All tobacco products and lighters will be returned to clients at time of discharge.

8. Clients must inform unit staff of special dietary needs or food allergies so that arrangements can be made with the food

service contractor.

9. Clothing items that advertise or glorify alcohol, drugs, sex, or violence cannot be worn.

10. Television will be turned off at 11 p.m.

11. Client phone calls are permitted during scheduled quiet times throughout the day. Times include: 1:15 pm - 2:45 pm, and 6:30 pm -7:00 pm (time limit of 10 minutes per person for calls).

12. Any physical contact between clients, including consensual sex, is prohibited.

13. Physical fighting, threats, harassment, damage to or theft of property are prohibited and may result in legal charges and

removal from the program.

I, ____________________________ have read the client guidelines outlined in the Admission Handbook and agree to

remain in compliance with these terms. If I experience difficulty with any aspect of it, I will approach staff for guidance.

_____________________________ __________________________ _____________________

Client Name Written: Client Signature: Date Signed:

_____________________________ __________________________ _____________________

Axis Staff Written: Axis Staff Signature: Date Signed:

AdmRef Checklist June 2018Opiate OrdersBCCSU Safety Bulletin and ContractCastlegar Plan G FormCastlegar - What to BringCastlegar Occupancy Guidelines (1)

Name: Phone Number: Address: Postal Code: PHN: Birthdate: Date Signed1: Patient has been hospitalized: OffWithout medication likely hospitalization: OffPatient suffer harm: OffName of Prescribing Physician: Practitioner ID: Date Signed2: Practitioner Phone: Practitioner Fax: Centre Name: Site Location ID: Name of Director or Designate: Designate Phone: Designate Fax: Date Signed3: Authorization Expiration: OffExpiry Date: Print: Clear Form: