DOCTOR’S ORDER SHEET
DRUG ALLERGIES:PATIENT IDENTIFICATION ROOM NO.
BEHAVIORAL Health – Opiate Addiction-Medication Assisted Treatment Orders
DATE
/TIME
/ORDERS FOR MEDICATION, DIET AND TREATMENTS
****** NO BENZODIAZIPINES ** NO STADOL ( butorphanol)******** NO NUBAIN (nalbuphine) ** NO ZOFRAN (ondansetron)**********
1. Notify attending physician of arrival
2. Initiate Clinical Opiate Withdrawal Scale (COWS)on admit , then every 2 hours x 24 hours. If score is
less than 25 during that period, assess every 4 hours until discharge. If condition changes or score is
25 or greater resume every 2 hour assessment.
3. Consult Social Services
4. Consult MFM
5. Consult Psychiatrist
6. Vital signs and pulse oximetry every 4 hours
7. Telemetry monitoring ( hold methadone and notify MD if QTc greater than or equal to 450ms)
8. Fingerstick Blood Glucose every 6 hours
9. Continuous Fetal Monitoring as indicated
10. Diet: NPO Clear liquid Full liquid Regular diet
11. Labs:
Urine Drug Screen on admit
EKG ( hold methadone and notify MD if QTc greater than or equal to 450ms
Daily Urine Drug Screen Urinalysis – mid stream clean catch ( C&S if indicated)
CBC HIV RPR Blood Alcohol Level CMP Hepatitis C
12. Start IV with 1000ml RL; run at 125ml/hr. Use 18 gauge cathalon for IV start, may use local
Anesthetic 1% Lidocaine (Xylocaine) at site.
Add 10 ml multivitamins to second liter of LR and infuse at 150 ml/hr. When completed,
change maintenance fluid to D5LR. If diabetic, continue with LR.
13. Thiamine 100 mg IM X 1 dose.
14. Medications:
Clonidine 0.1mg po tid. Check BP before each dose, hold if BP less than or equal to 90/60
Loperamide (Imodium ) 4 mg (2 tablets) po followed by 2 mg after each loose stool
Up to a maximum of 16mg/day ( 8 tablets / 24hrs) for diarrhea. Discontinue Loperamide if
no clinical improvement within 48 hours.
Cyclobenzaprine (Flexeril) 10mg po tid prn muscle cramps
HydrOXYzine pamoate (Vistaril) 25mg po every 4-6 hours prn for sleep or agitation
HydrOXYzine pamoate (Vistaril) 50 mg po every 4-6 hours prn sleep or agitation
HydrOXYzine (Vistaril) 25 mg IM every 4-6 hours prn sleep or agitation
HydrOXYzine (Vistaril) 50 mg IM every 4-6 hours prn sleep or agitation
Promethazine (Phenergan) 25 mg IM every 4 hours prn nausea
3/2016
DOCTOR’S ORDER SHEET
DRUG ALLERGIES:PATIENT IDENTIFICATION ROOM NO.
BEHAVIORAL Health - Opiate Addiction- Medication Assisted Treatment Orders
DATE
/TIME
/ORDERS FOR MEDICATION, DIET AND TREATMENTS
****** NO BENZODIAZIPINES ** NO STADOL (butorphanol )** **************** NO NUBAIN ( nalbuphine) ******* NO ZOFRAN ( ondansetron)
METHADONE Initiation ONLY : ( in addition to orders on page 1 of 2 )
Methadone 20mg po x 1 dose, repeat COWS in 2 hours.
IF COWS score greater than or equal to 13 give Methadone 10mg po x1 dose.
IF COWS score 5-12 give Methadone 5mg po x 1 dose.
IF COWS score less than 5, no additional Methadone. Repeat COWS score every 2 hours for 24 hours and
administer Methadone as above, not to exceed 40 mg of Methadone in a 24 hour period.
Methadone or Buprenorphine Maintenance:
Verify current dosage of maintenance medication with outpatient addiction provider per
Social Services prior to administration of maintenance dose.
Urine Drug Screen daily
Maintenance dose, Methadone ____mg po every Day
Maintenance dose, Buprenorphine:
Buprenorphine (Subutex) _____mg SL every Day
Buprenorphine ___mg /Naloxone ____ mg (Suboxone) SL every day
3/2016
Page 1 of 2