Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initiation of methadone maintenance treatment (MMT)
Continuation of MMT with review of progress and medication adherence
Adjustment of methadone dosage
Management of side effects or complications of methadone therapy
Addressing concerns about diversion or misuse of methadone
History of Present Illness:
For new patients initiating MMT:
History of opioid use disorder (OUD) including:
Type of opioid used (e.g., heroin, prescription pain medication)
Duration of opioid use
Routes of administration
Attempts at quitting or prior treatment experiences
Current symptoms of OUD (cravings, withdrawal)
Medical history relevant to methadone use (e.g., chronic pain, mental health conditions)
Social history (living situation, support system)
For established patients:
Progress since last visit
Adherence to medication schedule and counseling sessions
Changes in symptoms of OUD
Any new medical or social concerns
Medications:
List all current medications, including other medications that may interact with methadone.
Current methadone dose and route of administration (oral, dispensed liquid)
Physical Exam:
Brief physical exam focusing on:
Vital signs (heart rate, blood pressure, respiratory rate)
Signs of withdrawal or intoxication
Skin assessment for injection marks or abscesses (if applicable)
Assessment:
Opioid use disorder (OUD): Confirm diagnosis based on history and DSM-5 criteria.
Suitability for methadone maintenance treatment: Evaluate if MMT is the most appropriate treatment approach for the patient.
Current methadone dose: Assess if the current dose is adequately managing withdrawal symptoms and cravings without causing side effects.
Adherence to treatment plan: Evaluate adherence to medication schedule and counseling sessions.
Risk of diversion or misuse: Assess potential for misuse or diversion of methadone based on history and social circumstances.
Plan:
For new patients initiating MMT:
Discuss the benefits and risks of methadone treatment.
Obtain informed consent for treatment.
Initiate methadone at a low dose and gradually increase based on individual needs.
Schedule regular follow-up visits to monitor progress and adjust dosage as needed.
Refer for counseling and other support services (e.g., individual therapy, group therapy).
For established patients:
Continue methadone maintenance treatment if indicated.
Adjust methadone dose as needed to manage withdrawal symptoms and cravings.
Address any concerns about adherence, side effects, or potential misuse.
Encourage continued participation in counseling and other support services.
Consider tapering methadone if appropriate and the patient desires to discontinue treatment.
Education:
Educate the patient about MMT, including its benefits and risks, medication adherence, potential side effects, and the importance of attending counseling sessions.
Discuss safe storage and disposal of methadone.
Provide information on resources for relapse prevention and support groups.
Additional Considerations:
Document urine drug screen (UDS) results if performed.
Address any concerns about pregnancy or breastfeeding.
Consider the need for additional medications to manage co-occurring mental health conditions.
Collaborate with other healthcare providers involved in the patient’s care.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Methadone maintenance treatment is a regulated program with specific guidelines. Always refer to current regulations and best practices for methadone prescribing.