Buprenorphine (SUBOXONE) Treatment Policy

Outpatient Addiction Treatment Contract

Patient Name(Required)

First Name Last Name

Date of Birth(Required)

Buprenorphine (SUBOXONE) is a prescription medicine used to treat adults who are addicted to opioid drugs, as part of a complete treatment program that includes counseling, drug screenings, and behavior therapy.

Patient:

Agrees to never give their Buprenorphine to anyone else; it can cause death or otherwise harm them. Selling or giving away this medicine is against the law.
Agrees to tell their doctor about all medicines and illicit drugs they take.
Agrees to abstain from all drugs, both prescribed and illicit that has addictive potential, while in treatment on their road to recovery.
Agrees that the initial visit is an evaluation to assess their suitability for treatment, and medications may not be prescribed at this visit.
Agrees to be seen weekly for the first four visits, and then bi-weekly for the following two visits, and monthly thereafter.
Agrees to regular Drug Screenings (UDS or oral swabs) performed at the discretion of the prescriber, and results received and mist be negative for non-prescribed medications and any illicit drugs or treatment could result in a more intensive follow-up.
- UDS can be completed at an outside lab such as Quest or Labcorp. However, if you fail to do so, or test results are not received by our office at the time of an appointment, you must complete an office UDS at a cost of $30.
Understand and agrees that Buprenorphine is to be placed under the tongue for it to dissolve and be absorbed and that it should never be injected or taken IV. I have been informed that injecting Buprenorphine after taking Buprenorphine or any other opiate regularly could lead to sudden and severe opiate withdrawal.
I have been informed that my Positive Beginnings Provider will almost certainly (not start) or continue my Buprenorphine treatment if my urine is positive for alcohol or benzodiazepines.
Recognizes that buprenorphine has a high potential of abuse/dependence. The combination of buprenorphine with benzodiazepines can be dangerous. There is a high risk of death and coma if you take Buprenorphine with medicines such as benzodiazepines/alcohol. Patients will NOT be prescribed medications that have a high potential for dependence/addiction (benzodiazepines, stimulants, etc) unless it is deemed to be absolutely clinically necessary by the treating physician. Patients must disclose any prescriptions they receive from any other providers. ur providers will monitor the New Jersey prescription monitoring system on a regular basis.
Agrees to see a therapist for counseling and psychosocial therapy on a regular basis. This is vital in a recovery-based approach and is deemed mandatory by insurances for treatment.
Agrees that for continuity of care, follow up appointments will be scheduled with the same provider.
Agrees that it is the patient's responsibility to ensure that timely appointments are made and prescriptions filled so that they do not run out of medications.
Agrees to store medication properly, away from children, household members, guests, and pets. In case of overdose or another member taking the medications inadvertently, please call 911.
Agrees to always take SUBOXONE exactly as according to doctor's instructions. The doctor may change their dose according to response and tolerability. Do not change your dose unless your doctor tells you to change it.
Agrees to not take SUBOXONE more often than prescribed by their doctor.
Agrees to notify the doctor in case of relapse of drug abuse.
recognizes that buprenorphine itself is an opioid and can produce physical and psychological dependence.
Patient is made aware the safety of Buprenorphine on pregnancy has not been established. Patient agrees to inform their provider if they become pregnant.
Positive Beginnings reserves the right to require patients to bring their remaining doses of medication to each visit.
Caution is advised when driving or using power tools. Buprenorphine can lead to impairment of reflexes. It is the responsibility of the patient to be reasonably certain that the medication does not affect his/her ability to operate such machinery.
The clinic has a zero-tolerance policy for aggression and violence towards staff. If a patient or anyone accompanying them exhibits any such behaviors, a police charge may be filed and will be prosecuted to the fullest extent permissible by law.
In case of a missing to lost prescription.medication, a police report must be filed prior to a replacement script being issued.
If the above plan is not working, the patient will be referred to an Intensive Outpatient Program and/or rehab.

Consent(Required)

By signing this, you have read, understand, and agreed to the policy guidelines required while being treated by our Providers.

Signature(Required)

Date(Required)