THIS CASE RECORD FORM MAY BE DOWNLOADED FREE OF CHARGE


A COMPREHENSIVE CHEMICAL HEALTH RECORD

Please complete as much as you can of this record, if necessary with the help of family, friends and healthcarers. Then take it to your usual family doctor or counsellor. If you wish, send your completed record to Dr Beck for a written report on your condition and how it might possibly be managed. See Consultations

If you live in Perth make an appointment to see Dr Beck, with your completed case record.

Dr Neil Beck Fax : 61 (08) 9386 3333 Phone: 61 (08) 9386 8873 E-mail: [email protected]
Web Site: HeroinAddictionNaltrexone.com Postal address: 3/105 Broadway, Nedlands 6009 Western Australia
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For People who are excessively heavy users of the social drugs caffeine, nicotine, alcohol or cannabis; or who are dependent on, or addicted to, alcohol, amphetamines, cocaine, narcotics, or other illegal drugs; and who want to reassess themselves and any relevant causative or resultant, chemical, psychological or social problems they may suffer from; and to make changes in their medications, social drugs or hard drug usage.
family or code name or initial_______________________________________________________________________
forenames or code names or initials____________________________________________dob__________________
address (optional)____________________________________________phone____________________date_______
email address_______________________________________________fax no_______________________________
private health insurance________________________________________medicare no_________________________
G.P.___________________________________________________________________________________________
other healthcare professionals involved now or in the past________________________________________________
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1. BRIEFLY, WHAT IS THE PROBLEM YOU HAVE COME ABOUT?______________________
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2. WHAT PRESCRIBED MEDICATIONS, SOCIAL DRUGS AND ILLEGAL DRUGS ARE YOU TAKING AT PRESENT, OR HAVE YOU STOPPED TAKING RECENTLY; DAILY AMOUNTS; WHEN FIRST USED; IF STOPPED, WHEN?

a) prescribed medications_______________________________________________________________________
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b) social drugs_________________________________________________________________________________
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c) illegal drugs_________________________________________________________________________________
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d) your personal desires/goals re these medications and drugs_________________________________________
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e) other significant medications and drugs taken in past years_________________________________________
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f) methods used and outcomes from endeavours to change, reduce or cease taking medications and drugs___
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3. YOUR MEDICAL HISTORY
a) Please circle any of the following that you have experienced or still suffer from and then give details.
Head injuries, brain diseases, severe pain, sleeplessness, post traumatic stress syndrome, depression, manic depressive disorder, ADD or ADHD, anxiety, panic attacks, phobias, social phobia, severe agitation, serious anti-social behaviour, violent outbursts, rage, epilepsy, workaholism, excessive hurrying, obsessive compulsive disorder, compulsive sexuality, gambling or spending, anorexia, bulimia, allergy or sensitivity to any foods, drinks or confectionery, psychosis, suicide attempts, psychiatric hospital admissions, etc
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b) any other past or present diseases, operations or injuries: pregnancy or likelihood of pregnancy: medication sensitivities:_________________________________________________________________________
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c) your present LFT, Hep B & C and HIV status_______________________________________________________
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d) any other recent abnormal lab tests______________________________________________________________
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4. YOUR FAMILY HISTORY
What history is there amongst your children, nieces and nephews; brothers, sisters and cousins; parents, uncles and aunts; grandparents, great uncles and great aunts; of substantial artistic talent, originality or inventiveness, alcoholism, depression, manic depressive disorder, workaholism, anxiety or panic attacks, phobias & social phobia, ADD or ADHD, any mental illness, attempted suicide, suicide or unexplained deaths; of heavy consumption of caffeine, nicotine, or cannabis; or of dependence on, or addiction to, or dealing in, amphetamines, narcotics, or cocaine? Please circle the conditions suffered from, then put in M for Mother, PGF for Paternal Grandfather, etc, and then give details.
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5. YOUR SOCIAL HISTORY
a) Education; Did you suffer from learning difficulties, behaviour problems or frequent absenteeism in primary school or in high school? In what grade or year did you leave school? How many different primary schools and how many different high schools did you attend?
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b) Work; What difficulties if any have you had or do you have with employment? What work, if any, do you do now?
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c) Partner/s; What marriages, de facto relationships or serious sexual relationships have you had and what difficulties if any did you experience? Were there any really bad traumas? Does your sexuality cause you problems?_____________________________________________________________________________________
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d) Children; What children do you have and what sort of a relationship do you have with them? How are they getting along?_________________________________________________________________________________
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e) Your Home; What sort of a home do you live in, who do you share it with and is it satisfactory?__________
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f) Family of Origin: How many brothers and sisters did you have? Were you separated from any of them or from either of your parents as a child and if so, for what reason? Was it a happy family? What problems were there? Did your family ever move countries or cultures? Did you move houses often?_____________________
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g) Main Supporters; Who are the main people amongst your family, friends, healthcarers etc who would stand by you in time of need? Who would help to look after you during detoxification?__________________________
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h) Other Users; Are there any amphetamine, cocaine or narcotic users or dealers amongst your flatmates, friends or work mates?__________________________________________________________________________
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i) Worst Experiences; What have been the worst experiences in your life? e.g. physical or sexual abuse, divorces, deaths, loss of a child, sexual problems, financial disasters, war experiences, jail etc; what are the personal issues that you agonize over most?________________________________________________________
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j) Crime; What past and current police and court matters have you been involved in?______________________
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k) Hopes; What are your loves, hopes and plans? ____________________________________________________
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______________________________________________________________________________________________6. YOUR ASSESSMENT OF YOUR PROBLEMS
If you can, make a summary of what you believe are your main problems________________________________
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Make a summary of all the factors that you think may have contributed to your need for, dependence on, or addiction to, medications and drugs. Then underline what you think were the most important factors.
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7. THE DIAGNOSIS
Consultant's summary of the patient's diagnoses & their causes_______________________________________
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8. WHAT YOU WANT AND ARE READY FOR
a) What are you really seeking/wanting?
____________________________________________________________________________________________________________________________________________________________________________________________Consultant's Views:
____________________________________________________________________________________________________________________________________________________________________________________________b) What are your personal goals and timeframes? Where do you want to be in 5 years?____________________
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Consultant's Views:_____________________________________________________________________________
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c) What stage are you at now? What are you ready for now?
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Consultant's Views:
____________________________________________________________________________________________________________________________________________________________________________________________d) What do you consider to be your level of motivation and genuine desire to work and grow and change, in order to get what you want?______________________________________________________________________
Consultant's Views:_____________________________________________________________________________
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9. MULTIDISCIPLINARY MANAGEMENT PLAN
(a) Supporters, Consultants & Referrals Needed_____________________________________________________
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(b) Recommended reading, meetings, groups, classes, web sites_______________________________________
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(c) Protocols recommended______________________________________________________________________
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(d) Types of Medication needed___________________________________________________________________
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(e) Initial Drug Modifications______________________________________________________________________
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(f) IInitial Prescriptions__________________________________________________________________________
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(g) Patient Consent. I have had this plan presented to me and discussed with me and I am in agreement with it.
Signed: ______________________________________


PROGRESS NOTES INITIALS:_________ D.O.B:___________
1. naltrexone compliance. 2. sleep. 3. psych. 4. motivation, determination & morale. 5. d. & v. & hydration 6. appetite. 7 energy. 8. family. 9. buddies. 10. work. 11. lab results & requests. 12. referrals _ 13. scripts_ _14. present medications._ 15. illegal drugs._ _ 16. next appt. 17. overall progress
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family or code name:________________________given or code names:_____________________________d.o.b._____________

A RAPID DETOXIFICATION/ NALTREXONE TREATMENT UNDERSTANDING
(These understandings apply in a scaled down manner to Incremental (Stepped) Rapid Detox )


Please read the following and circle any points you need to discuss further. Initial the ones you are happy with.

1. I understand that Rapid Detoxification means the displacement of all narcotics from my brain and nerves in an hour, using oral or injected medications. I understand that Rapid Detoxification will give me narcotic withdrawal symptoms which can range from mild, if I have taken very little narcotic in the previous few days, to severe, if I have used narcotics right up until the day before Rapid Detoxification. I understand the withdrawal symptoms may include sweats, vomiting and diarrhoea, abdominal cramps, muscle and bone aches, restlessness, sleeplessness and dehydration. I understand it is my responsibility to get my narcotic intake down as low as possible for the 3 days prior to Rapid Detoxification, with the help of clonidine (catapres) and other medications, in order to minimise these withdrawal symptoms.

2. I understand that the medications used in Rapid Detox may include narcan (naloxone), a fast but short acting medication which displaces narcotics from the nerve receptors and which itself has few side effects; sedatives such as oral temazepam and serepax and intravenous valium or midazolam; maxalon and ondansetron for nausea and vomiting; octreotide and imodium for diarrhoea; clonidine, buscopan and quinine bisulfate for cramps and surgam or celebrex for aches and pains. I understand that the rapid withdrawal of the narcotic, together with the absorption of the multiple medications used, may make me feel mildly to severely uncomfortable and unwell for a few hours to a few days, depending on the narcotic load that I am carrying at the time of treatment and the amount of medication needed to deal with that level of narcotics.

3. I understand that the Naltrexone Maintenance Programme is the key to staying off narcotics because as long as I take it, Naltrexone will stop me from craving and because narcotics taken whilst I am on Naltrexone, will not give me a high.

4. I understand that naltrexone has Therapeutic Goods Administration approval for the maintenance treatment of alcohol abuse and narcotic addiction, but is not yet approved by the TGA for Rapid Detoxification and that it will therefore usually be given to me towards the end of Rapid Detoxification using narcan.

5. I understand that naltrexone should, if possible, be avoided or administered in reduced doses if I have serious liver or kidney disease, and can also occasionally cause a number of minor symptoms. I understand that the symptoms are mild gut disturbance (nausea, loss of appetite or diarrhoea) and anxiety with mild shakiness and sleeplessness. I understand that if these problems occur it may be helpful to take half a tablet once or twice a day, rather than a whole tablet once a day and that naltrexone should be avoided in the evening unless accidentally missed earlier in the day. I understand these problems usually pass off after a short period of taking the medication. I understand that if I take a naltrexone tablet whilst currently using narcotics, sudden and severe withdrawal symptoms will occur and I will vomit severely for 2 days and be very unwell and that I should avoid doing this.

6. I understand that the effect of naltrexone on an unborn baby is not known, but is probably less than the effect of heroin addiction on an unborn baby. I understand that naltrexone increases female fertility and likelihood of conception and that contraception should be highly efficient during addiction and naltrexone treatment.

7. I understand that if I come off narcotics, whether by Rapid Detoxification and naltrexone or by any other method, I will lose my tolerance for those narcotics within a few days. I understand that if, for any reason, I stop the naltrexone within the first 6 to 12 months, I will have a high likelihood of going back onto narcotics within a few days. I understand that unless I go back on a substantially reduced dose of narcotic, I will be at great risk of overdosing with the first 3 or 4 hits, because of loss of tolerance whilst off the narcotic.

8. I understand that the fee for Rapid Detoxification, expensive drugs often used on Detoxification Day, e.g. I.V. clonidine, narcan, midazolam, ondansetron, octreotide and 4 days supply of naltrexone, is $.................. I will pay this fee promptly, with at least $.............. paid as a deposit on booking in for Rapid Detoxification. My guarantor .................................................................will pay the balance of this fee within thirty days if I am unable to do so. ($50 discount if fully paid within 30 days of treatment.)

9. I understand that consultations prior to, and after, Detoxification Day are charged separately from the $............ Detoxification Day fee, or bulk billed if appropriate. I understand that other medications will need to be purchased from a pharmacy with prescriptions supplied at the consultations and that the treatment will probably fail if I don't bring money for the pharmacy and don't get these medications.

10. I understand that naltrexone is the key to staying off heroin and that I and my Buddy must make very reliable ongoing arrangements to get naltrexone from a "Next Step" clinic (free) or a pharmacy (approximately $7.00 per tablet). I understand that I am likely to revert to heroin within 1 or 2 days if I run out of naltrexone soon after detoxification, and that the main focus of my life for the next three years must be getting and taking my naltrexone each and every day. I understand that I will need to be detoxed again at a cost of $.................. if I am back on heroin for more than a day or two. I understand that I must ring or return to the Clinic urgently for advice if I am tempted or I do start to use narcotics again.

11. I understand that if I am prescribed S8 medications, such as rohypnol (flunitrazepam), temgesic or methadone, I will automatically be registered as an addict by the Health Department, which has to give permission for such prescriptions. I understand that the Health Department cannot pass this information on to employers, Police or anyone else except other doctors I may consult.

12. I understand that information from my case details may be included in reports and research efforts, to find more effective means of treating drug addiction, but that my name or identity will never be revealed or made public in any way.

13. I have read the above statements, have had my questions about them answered and understand the points made.

Signed by patient:________________________________ Buddy 1_________________________phone___________
Guarantor____________________________ phone________________ Buddy 2___________________________
phone_____________________________

Clinic Rep______________________________ date:___________________________

Family or code name_________________________Given or code names___________________________dob_____________

Fax No, Postal or Email Address_____________________________________________________________________________