Suboxone/ Buprenorphine Consent Form

Suboxone/ Buprenorphine

As a participant in medication treatment for opioid misuse or dependence, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep, and be on time to, all my scheduled appointments.

2. I agree to adhere to the payment policy outlined by this office.

3. I agree to conduct myself in a courteous manner when speaking with the office staff.

4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I understand that if dealing, selling or any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without any recourse for appeal.

6. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit will result in my not being able to get my medication/prescription until the next scheduled visit. (In Rare emergencies a “bridge” may be provided but is at the sole discretion of your MAPS provider. Bridges will come with an associated fee that must be paid prior to the prescription and bridges have a separate agreement, not covered here).

7. I agree to make another appointment in case of a lost prescription or stolen medication.

8. I agree to store medication properly. Medication may be harmful to children, household members, guests, and pets. The Suboxone/Buprenorphine Film should be stored in a safe place, out of the reach of children. If anyone besides the patients ingests the medication, I agree to call the Poison Control Center (800) 222-1222 or dial 911 immediately.

9. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. I understand that mixing this medicine with other medications, especially benzodiazepines (for example deaths have occurred among persons mixing buprenorphine and benzodiazepines, especially if taken outside the care of a physician, using routes of administration other than sublingual or in higher than recommended therapeutic doses).

10. I agree to read the education material provided by most pharmacies with prescription medications. I agree to consult my MAPS provider should I have any questions or concerns about side effects I experience.

11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.

12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as well as attending the chemical dependency rehab program and other support groups as discussed and agreed upon with my doctor and specified in my treatment plan.

13. I agree to notify the clinic in case of a relapse or return to drug abuse. Relapse to opiate drug abuse can result in being removed from the Suboxone/ buprenorphine program. An appropriate treatment plan must be developed as soon as possible. The physician should be informed of a relapse before random urine testing reveals it.

Follow Up Appointment Protocol

14. I agree to the guidelines of office operations. I understand the procedure for making appointments and paying for missed appointments and late cancellation fees. I have the phone number of this clinic and I understand the office hours. I understand that no medications will be prescribed by phone on Fridays, nor do we refill medications on weekends. I understand that I am required to abide by these restraints to remain on the Suboxone/ buprenorphine treatment.

15. I agree to comply with the required film counts, saliva test and urine tests. Urine/ saliva testing is a state/ federal mandatory part of office maintenance.

16. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances.

17. I agree to provide a drug screens by a) witnessed saliva test or b)urine drug screens when asked to do so by MAPS health care team.

18. I understand that violations of the above may be grounds for termination of treatment.

19. I understand that the phone numbers I give will be used to contact me to remind me of appointments. I give my permission for the office staff to leave messages on these phone numbers.

Follow up appointments will be at least monthly. The visits are focused on evaluating compliance and the possibility of relapse.

They include: • Film/ tablet counts

• An interim history of any new medical problems or social stressors

• Prescription of medication

• No refills of Suboxone Buprenorphine will be made for any reason except during a clinic visit.

• Appointments do not include evaluation or care for other problems outside of Suboxone/ Buprenorphine management. Should you have other medical conditions that you wish to address, you will need to schedule a separate appointment.

Dangerous behavior, relapse, and relapse prevention.

The following behavior “red flags” will be addressed with the patient as soon as they are noticed:

• Missing appointments • Running out of medication too soon & Taking medication off schedule

• Refusing urine testing

• Neglecting to mention new medication or outside treatment

• Agitated behavior

• Frequent or urgent inappropriate phone calls

• Outbursts of anger

• Lost or stolen medication

• Non-payment of visit bills as agreed, missed appointments or cancellations within 24 hours of your appointment

• Treatment may be discontinued if these behaviors occur.

Informed Consent

INFORMED CONSENT

Please read this information carefully. Suboxone (buprenorphine + naloxone) is an FDA approved medication for treatment of people with opiate (narcotic) dependence. Suboxone is a weak opiate and reverses actions of other opiates. It can cause a withdrawal reaction from standard narcotics or Methadone while at the same time having a mild narcotic pain-relieving effect from the Suboxone. The use of Suboxone can result in physical dependence of the buprenorphine, but withdrawal is much milder and slower than with heroin or Methadone. If Suboxone is suddenly discontinued, patients will have only mild symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone may be discontinued gradually, usually over several weeks or more. Some patients find that it takes several days to get used to the transition to Suboxone from the opiate they had been using. After stabilized on Suboxone, other opiates will have virtually no effect. Attempts to override the Suboxone by taking more opiates could result in an opiate overdose. Do not take any other medication without discussing it with you physician first. Combining Suboxone with alcohol or some other medications may also be hazardous. The combination of Suboxone with mediation such as Valium, Librium, Ativan, or Xanax has resulted in deaths.

The form of Suboxone given in this program is a combination of buprenorphine with a short- acting opiate blocker, naloxone. If the Suboxone Film was dissolved and injected by someone taking heroin or another strong opiate, it would cause severe opiate withdrawal. Suboxone Film must be held under the tongue until completely dissolved. It is then absorbed from the tissue under the tongue. If swallowed, Suboxone is not well absorbed from the stomach and the desired benefit will not be experienced.

We do not prescribe, under any circumstances, narcotics, Methadone, or sedatives for patients desiring maintenance or detoxification from narcotics. All Suboxone must be purchased at private pharmacies. We will not supply any Suboxone.

Treatment Maintenance

Suboxone / buprenorphine treatment may be discontinued for several reasons:

• Suboxone / Buprenorphine controls withdrawal symptoms and is an excellent maintenance treatment for many patients. If you are unable to stop your heroin abuse or if you continue to feel like using narcotics, even at the top doses of Suboxone, the doctor will discontinue treatment with Suboxone/Buprenorphine, and you will be required to seek help elsewhere.

• There are certain rules and patient agreements that are part of Suboxone treatment. All patients are required to read and acknowledge these agreements by signature upon admission to the treatment panel. If you do not abide by these agreements, you may be discharged from the Suboxone treatment program.

• Prompt payment of clinic fees is part of this program. If your account does not remain current as agreed, appointments cannot be scheduled. If appointments cannot be kept as agreed, your status as an active patient may be cancelled.

• In the rare case of an allergic reaction to medication, Suboxone/ Buprenorphine must be discontinued.

• Dangerous threats or inappropriate behavior toward our staff will result in your discharge from the Suboxone/ Buprenorphine treatment. This includes patients who are intoxicated or on other narcotics, Valium, barbiturates, or Xanax like medications.

• In the case of dangerous threats or behavior there will be no two-week taper. You will be discharged and asked not to return to the clinic.

By signing this treatment information and consent form, I the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

Patient First Name *

Patient Last Name *

DOB

Date

Patient Signature Name

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CONSENT FORM

CONSENT FORM

MAPS for Recovery