Buprenorphine Informed Consent and Treatment Agreement

I understand that Suboxone is a combination of buprenorphine and naloxone. Nalxone will counter act any opioid I’m taking, causing precipitated withdrawal. I understand I must take Suboxone as ordered and follow instructions outlined.

I understand that buprenorphine is a narcotic drug that, if taken in large quantities, can produce a ‘high’. I know that if I abruptly stop taking it, I could experience opioid withdrawal symptoms.

I have had the opportunity to discuss various options for treatment of my addiction with my healthcare team, including non-pharmacological options. They have explained, and I understand, the risks and benefits of buprenorphine, including potential side effects. These include but are not limited to constipation, sedation, respiratory depression, overdose, and death. I understand that in order to be a satisfactory candidate for buprenorphine treatment, I must follow certain safety precautions for the treatment and comply with the treatment the schedule prepared for me by my prescriber. Additionally, my health care team has discussed this agreement with me and explained what is expected of me in the program. I have been given information about the program and have had adequate time to have my questions answered.

I will take buprenorphine by placing it under my tongue to dissolve and be absorbed. I will never inject buprenorphine or take it intravenously (IV), because IV use could lead to sudden and severe opiate withdrawal.

I will not drive a motor vehicle or use power tools or other dangerous machinery while taking Suboxone until my doctor has cleared me to do so.

I will inform my MAT provider and care team of all my other doctor and dentist appointments and any medications (prescription or non-prescription) that I am taking. I will also report any change in my medical history.

I understand that mixing buprenorphine with alcohol or other sedatives (such as Valium, Ativan, Xanax, Klonopin, Librium), benzodiazepines can be dangerous. The result could be accidental overdose, over-sedation, organ failure, coma, or death. I agree to abstain from alcohol and sedatives while I am taking buprenorphine, unless explicitly discussed with my buprenoprhine prescriber.

I understand that continued use of other drugs can interfere with my attempts at recovering from opioid dependence. I also understand that buprenorphine (as found in Suboxone) is designed to treat opioid dependence, not addiction to other classes of drugs. Therefore, I will work with the MAT provider to design an individualized treatment program to assist me in discontinuing the use of any other drugs I am using.

My medication must be protected from theft or unauthorized use. I understand that buprenorphine must be stored safely and securely where it cannot be taken accidentally by children, pets, or be stolen. If my medications are stolen, I will file a report with the police and bring a copy to my next visit. If another person ingests my buprenorphine, I will immediately call 911 or Poison Control at 1-800-222-1222. I agree to take full responsibility for the safekeeping of my buprenorphine. Lost or stolen buprenorphin will not be refilled before the date it was due.

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 may result in my treatment being terminated without recourse for appeal.

I understand that buprenorphine refills are only provided at scheduled visits, and not by phone, texting, or any other means. If I miss my visit, I must reschedule in order for my prescription to be refilled.

I must take my medications as instructed by my buprenorphine provider. I cannot change the way I take my medications or adjust the dose until approved by my buprenorphine provider.

I agree to see my buprenorphine provider on a regular basis. The frequency of visits will be up to my buprenorphine provider and will be explained to me.

If I miss an appointment or if I need to reschedule an appointment for a later date, I understand that my medications will not be refilled until the time of my next scheduled appointment with a buprenorphine provider. I understand that if I miss or am late to three appointments and did not call the clinic in advance and provide at least 24hr notice I will be dismissed from the buprenorphine maintenance clinic and I will not be given any refills for my medication. I may also be given a lower dose, enough to avoid withdrawal.

I understand that my buprenorphine provider will monitor my medication compliance by doing urine or blood drug screens at my cost. I consent to testing for this purpose and I understand that it is a requirement of my participation in the buprenorphine clinic. Missed drug screens will be considered to be “positive” screens (meaning that they will be interperated as missing buprenorphine or containing unpresribed substances), and may lead to change in visit frequency, change in screening frequency, change in dose, and if persistent, dismissal from the program.

I agree to notify the clinic immediately in case of relapse to opioid drug abuse. Relapse can be life threatening, and an appropriate treatment plan must be developed as soon as possible. I understand the provider should be informed about relapse before any urine test shows it.

I agree to conduct myself in a courteous manner in the physician’s or clinic’s offices.

I understand that if I do not uphold this agreement, I will be dismissed from the program.

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