Section 440IAC10-4-16. Initial assessment

   (a) An initial assessment shall be made upon admission to an OTP and shall meet the following requirements:

(1) Be fully documented in the patient's record.

(2) Be conducted by a program physician.

(3) Include all measures and procedures necessary to determine opioid addiction.

Only a program physician shall perform an initial assessment.

  (b) The initial assessment shall include the following:

(1) Observation of the signs and symptoms of opioid withdrawal.

(2) Obtaining an opioid use and addiction history.

(3) Drug testing, which shall include testing for the presence of the following:

(A) Methadone.

(B) Cocaine.

(C) Opiates.

(D) Amphetamines.

(E) Barbiturates.

(F) Tetrahydrocannabinol.

(G) Benzodiazepines.

(H) Any other suspected or known drug that may have been abused by the patient.

(4) Pregnancy testing, as medically appropriate.

(5) A physical examination.

(6) The risks and benefits of treatment medication and appropriate alternative procedures or courses of treatment shall be explained to the applicant. Documentation that this explanation was made shall be included in an admitted patient's record.

  (c) Documentation of the following shall be retained in a patient's record:

(1) Individuals applying for admission to an OTP shall voluntarily choose opioid addiction treatment.

(2) All relevant facts concerning the use of opioid treatment medication shall be clearly and adequately explained to the individual.

(3) Each patient being admitted to treatment shall provide written informed consent to treatment.

  (d) All psychoactive prescription medications detected by drug testing shall be documented in the patient's record.

  (e) With appropriate written authorization for the release of information, the program staff shall do the following:

(1) Make contact with the physician prescribing the psychoactive prescription medications in subsection (d).

(2) Explore the need for the medication.

(3) Document in the patient's record the justification for the continued use of the medication if the use is contraindicated with the use of opioid treatment medication.

  (f) Enrolled patients who are taking prescription medication or medications that may adversely interact with opioid treatment medication shall be advised of the following:

(1) The contraindications for the use of prescription medications with opioid treatment medication.

(2) The need to consider the following:

(A) Alternative prescriptions.

(B) Over-the-counter medication or medications.

(C) Alternative treatment protocols.

  (g) An OTP shall give written notice to an individual seeking treatment that, if the individual refuses or fails to give the written authorization for release of information required under subsection (e), the OTP may refuse to admit the individual.

  (h) The OTP shall document in the patient's record the OTP's request for written authorization for the release of information in subsection (e). (Division of Mental Health and Addiction; 440 IAC 10-4-16; filed Dec 30, 2009, 2:00 p.m.: 20100127-IR-440080412FRA; filed Feb 16, 2015, 1:02 p.m.: 20150318-IR-440140343FRA; readopted filed May 10, 2016, 11:24 a.m.: 20160608-IR-440160134RFA)