Addiction Medicine Consultation Note (Inpatient)

Date/Time: [Encounter date and time]

Patient Location: [Unit and bed]

Referring Service: [Team name and clinician]

Consult Type: [initial / follow-up]

Primary Reason for Hospitalization: [One-line reason]

Reason for Consult

[Consult question, urgency, and specific deliverables requested] (Write 1–3 short statements using the referrer's words when available. Examples: MOUD initiation, withdrawal management, pain management alignment, discharge linkage.)

Data Sources and Limitations

[Information sources and reliability concerns] (List sources: patient interview, chart review, collateral contacts, PDMP, pharmacy verification, nursing observations, labs/toxicology. Note reliability concerns: intoxication, sedation, cognitive impairment, language barriers. State consent status for outside contacts. When key data are missing, state "unknown" or "unable to verify.")

Clinical Summary

[Single-sentence case frame: patient descriptor, reason hospitalized, key substance use issue, immediate clinical concern]

Patient Goals and Preferences

[Patient-stated goals for hospitalization and after discharge; treatment preferences; anticipated barriers] (Include direct quotes selectively to convey goals, readiness, and concerns. Note practical barriers: transportation, housing, insurance, stigma. If unknown, state "patient goals not elicited" or "unknown.")

History of Present Illness

[Narrative of substance-related precipitant to admission] (Begin with the trigger: overdose, withdrawal, infection, or intoxication-related injury. Include timeline of last use and symptom onset, current withdrawal or intoxication symptoms, inpatient interventions so far with response, and relevant prior treatment experiences influencing today's plan.)

Substance Use History

(Include only substances relevant to the consult. Omit non-pertinent substances.)

• Opioids: [Prescribed vs illicit; fentanyl exposure; route; frequency and quantity; last use; typical withdrawal timeline; history of complicated withdrawal or overdose; prior treatment and outcomes; periods of recovery; current motivation and barriers]
• Alcohol: [Pattern in standard drinks; duration of heavy use; last drink; history of seizures or DTs; prior treatment and recovery; current motivation and barriers]
• Stimulants: [Type; route; pattern; last use; complications; prior treatment; motivation and barriers]
• Benzodiazepines/Sedatives: [Prescribed vs non-prescribed; doses; duration; last use; withdrawal history; overdose risk with other depressants]
• Cannabis: [Pattern; last use; related concerns or treatment interest]
• Nicotine/Tobacco: [Products; quantity; prior quit attempts; interest in pharmacotherapy]

Substance-Specific Assessment

(Include only relevant subsections.)

Opioids

• OUD diagnosis: [DSM-5 criteria met / probable / by history] — [Supporting evidence]
• Withdrawal status: [none / mild / moderate / severe]; [Objective signs: COWS score and time if used; vitals; pupils; GI symptoms; diaphoresis]
• MOUD history: [Prior medications; effectiveness; adverse effects; adherence]
• Pain considerations: [Acute or chronic pain; current regimen; alignment with MOUD]
• Safety considerations: [Concurrent sedatives; respiratory risk; QTc if methadone considered; hepatic or renal function]

Alcohol

• Use pattern: [Standard drinks per day; duration; last drink]
• Withdrawal risk: [History of complicated withdrawal; current symptoms; monitoring approach] (Note CIWA-Ar limitations if applicable.)
• AUD pharmacotherapy: [Interest level; contraindications for naltrexone, acamprosate, or disulfiram]

Stimulants

• Current state: [Intoxication or withdrawal symptoms; acute safety concerns: agitation, psychosis, chest pain, hyperthermia]
• Co-occurring conditions: [ADHD history or considerations]
• Treatment interest: [Behavioral treatment; harm reduction needs]

Sedative-Hypnotics

• Exposure: [Prescribed vs non-prescribed; specific agents and doses; duration]
• Risk: [Overdose synergy with other depressants; withdrawal risk]

Psychiatric History

[Diagnoses; treatment history; current symptoms; current psychiatric medications] (Distinguish substance-induced vs primary when applicable. Include suicide and self-harm risk assessment when indicated: ideation, intent, plan, means, protective factors. Note capacity considerations if relevant.)

Medical History

[Addiction-relevant comorbidities] (Include: infectious complications with status and treatment—HIV, HCV, HBV, SSTI, endocarditis; hepatic and renal function; chronic pain history; pregnancy or breastfeeding when relevant; medication interactions.)

Current Medications

• Home medications: [List with doses] (Highlight MOUD, benzodiazepines, opioids, gabapentinoids.)
• Inpatient medications: [Medications affecting withdrawal, sedation, or treatment plan]
• Allergies: [Allergies with reaction type] (Distinguish true allergies from side effects.)
• Verification status: [Controlled substances verified via pharmacy, prescriber, or PDMP vs patient-reported vs unable to verify]

Social History and Discharge Feasibility

• Housing: [Status and stability]
• Phone access: [Availability; preferred contact method]
• Transportation: [Availability and constraints]
• Insurance and pharmacy: [Coverage; pharmacy access; prior barriers]
• Legal considerations: [Probation; pending cases; court-mandated treatment]
• Supports: [Family or friends; consent to involve]
• Outpatient engagement: [Prior barriers; preferred follow-up modality]

Physical Examination

• General: [Appearance; level of arousal; distress]
• Vital signs: [Current values; trends if relevant]
• Substance-related findings: [Pupils; diaphoresis; tremor]
• Skin and injection sites: [Track marks; SSTI; wounds]
• Cardiovascular and respiratory: [Pertinent findings]
• Mental status exam: [Appearance; behavior; speech; mood and affect; thought process and content; perceptions; insight; judgment] (Include when psychiatric concerns present.)

Objective Data Reviewed

Labs

[Relevant results with values and dates] (Include CBC, CMP, LFTs, pregnancy test, others as indicated.)

Toxicology

[UDS results with interpretation] (Note limitations, detection windows, expected vs unexpected findings.)

PDMP

[Summary of review: controlled substance fills, prescribers, pharmacies, concerns] (Include date range reviewed.)

Other

[EKG with QTc; imaging; cultures] (Include when relevant to substance complications.)

Assessment

(Prioritize by acuity. Use DSM-5 terminology with severity when formally diagnosed; use "probable" or "by history" when provisional.)

• [Problem 1]: [Diagnosis and severity] — [Supporting evidence]
• [Problem 2]: [Diagnosis] — [Supporting evidence]
• [Additional problems as needed]

• Withdrawal status: [none / mild / moderate / severe]; [Complication risk]
• Co-occurring psychiatric conditions: [Diagnoses with substance-induced differential if applicable]
• Acute medical issues: [Issues affecting treatment choices]
• Risk assessment: [Overdose risk factors]; [Suicide risk if evaluated]; [AMA risk with contributing factors]

Plan

(Organize by problem. Address inpatient actions, monitoring, and discharge plan. Distinguish verified vs patient-reported information.)

OUD/Opioid Withdrawal

(Include when applicable.)

• MOUD decision: [Options discussed; patient preference and rationale; medication and dose plan; contraindications considered]
• Withdrawal management: [Symptom-triggered vs scheduled; monitoring tool; adjustment parameters]
• Pain management: [Multimodal plan aligned with MOUD]
• Safety measures: [Respiratory and sedation risk mitigation if concurrent CNS depressants]
• Naloxone: [Inpatient education completed; discharge supply plan]
• Discharge MOUD: [Medication; dose; prescriber; start date; bridge prescription]
• Follow-up: [Destination: OTP / office-based / bridge clinic]; [Appointment date and time if scheduled]; [Transportation plan]; [Contingency if missed]

(Regulatory note: Methadone for OUD maintenance requires OTP dispensing; the 72-hour rule permits limited emergency administration while arranging referral.)

AUD/Alcohol Withdrawal

(Include when applicable.)

• Withdrawal protocol: [Monitoring tool; escalation indications]
• Medications: [Benzodiazepines and adjuncts; thiamine and nutrition]
• AUD pharmacotherapy: [Relapse prevention options; chosen therapy; contraindications]
• Discharge linkage: [Treatment referral and scheduling]

Stimulant Use Disorder

(Include when applicable.)

• Acute safety: [Management of agitation, psychosis, hyperthermia, or chest pain]
• Withdrawal support: [Sleep, nutrition, mood support; symptomatic medications]
• Behavioral treatment: [Referral; contingency management availability]
• Harm reduction: [Fentanyl contamination counseling; safer use strategies]

Sedative-Hypnotic Considerations

(Include when applicable.)

• Taper or continuation: [Rationale; schedule; monitoring]
• Overdose risk: [Synergy with opioids, alcohol, or gabapentinoids; mitigation plan]

Nicotine/Tobacco

(Include when applicable.)

• Inpatient therapy: [NRT or pharmacotherapy; dosing]
• Discharge plan: [Continuation; quit resources]

Harm Reduction and Preventive Care

• Screening: [HIV, HCV, HBV status and plan]
• Vaccination: [HAV, HBV if indicated]
• Safer injection: [Syringe services linkage; wound care education] (If applicable.)
• PrEP: [Counseling if indicated]

Discharge Linkage Summary

• MOUD at discharge: [Medication; dose; prescriber; bridge supply]
• Follow-up appointment: [Location; date and time; contact; transportation]
• Naloxone: [Dispensed or prescribed; education completed]
• Care coordination: [Warm handoff status; responsible parties]
• Contingency: [Plan if follow-up missed]

Patient Education and Shared Decision-Making

[Options discussed; patient preference; key risks reviewed; consent for MOUD and information sharing] (Risks to address: precipitated withdrawal timing, overdose risk after tolerance loss, sedation risks. If patient declines recommended treatment: document capacity assessment if indicated, reasons for refusal, alternatives offered, harm reduction provided.)

Coordination and Communication

• Primary team: [Orders needed; monitoring instructions; discharge steps]
• Outpatient coordination: [Communications to providers, OTP, or pharmacy; consent status]
• Addiction medicine follow-up: [Planned check-ins; re-consultation criteria]