BUPRENORPHINE MAINTENANCE TREATMENT CONSENT
FIRST MIDDLE LAST
Patient information and consent to treatment with buprenorphine Suboxone (a tablet with buprenorphine and naloxone) is an FDA approved medication for treatment of people with heroin or other opioid addiction. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long a medically necessary. There are other treatments for opiate addiction, including methadone, naltrexone, and some treatments without medications that include counseling, groups and meetings.
If you are dependent on opiates any opiates - you should be in as much withdrawal as possible when you take the first dose of buprenorphine. It you are not in withdrawal, buprenorphine can cause severe opiate withdrawal. For that reason, you should take the first dose in the office and remain in the office for at least 2 hours. We recommend that you arrange not to drive after your first dose, because some patients get drowsy until the correct dose is determined for them.
Some patients find that it takes several days to get used to the transition from the opiate they had been using to buprenorphine. During that time, any use of other opiates may cause an increase in symptoms. After you become stabilized on buprenorphine, it is expected that other opiates will have less effect. Attempts to override the buprenorphine by taking more opiates could result in an opiate overdose. You should not take any other medication without discussing it with the physician first.
Combining buprenorphine with alcohol or other sedating medications is dangerous. The combination of buprenorphine with benzodiazepines (such as Valium, Librium, Ativan, Xanax, Klonopin, etc.) has resulted in deaths.
Although sublingual buprenorphine has not been shown to be liver-damaging, we may monitor your liver tests while you are taking buprenorphine. (This is a blood test.)
The most common form of buprenorphine (Suboxone now generic buprenorphine/naloxone or Zubsolv) you will be taking is a combination of buprenorphine with a short acting opiate blocker (Naloxone). It will maintain physical dependence, and if you discontinue it suddenly, you will likely experience withdrawal. If you are not already dependent, you should not take buprenorphine, it could eventually cause physical dependence. There are some patients who are allergic to the naloxone component and in that case, they may receive plain buprenorphine.
Buprenorphine film or tablets must be held under the tongue until they dissolve completely. If you never had it before, we will usually give your first dose at the clinic, and you will have to wait as it dissolves, and for one hour after it dissolves, to see how you react. It is important not to talk or swallow until the film or tablet dissolves. This can take up to ten minutes if the tablet. Buprenorphine is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Buprenorphine will not be absorbed from the stomach if it is swallowed. If you swallow the film or tablet, you will not have the important benefits of the medication, and it may not relieve your withdrawal.
Many patients initially may require a daily dose of 16 mg to 24mg of buprenorphine. (This is roughly equivalent to 60mg of methadone maintenance) Beyond that dose, the effects of buprenorphine plateau, so there may not be any more benefit to increase in dose. It may take several weeks to determine just the right dose for you. After several months we will discussing tapering from the medication.
Key Points of Maintenance
The maintenance phase may continue indefinitely; you will be assessed for cravings and adherence to psychosocial therapies.
Opioid abuse should not be grounds for terminating buprenorphine treatment. While I do not encourage opioid abuse, the reality is that there is a high relapse rate. I am here to help and try to steer you out of the addiction.
Stable patients may wish to be tapered off of buprenorphine, but many will need to return to maintenance therapy, as the addiction is often impossible to cure.
Modifications to buprenorphine treatment are needed for the following special populations: methadone patients, pregnant, adolescents, geriatric patients, and patients with chronic pain
These groups have in common that some special precaution must be added for buprenorphine treatment.
If you are transferring to Suboxone from methadone maintenance, your dose has to be tapered until you have been below 30mg for at least a week. There must be at least 24 hours (preferably longer) between the time you take your last methadone dose and the time you are given your first dose of buprenorphine. Your doctor will examine you for clear signs of withdrawal, and you will not be given buprenorphine until you are in withdrawal.
1. Only Dr. Kenneth Zahl or a designated covering physician or licensed practitioner will prescribe BUPRENORPHINE. I am not permitted to get such medication from any other doctor or clinic. By typing my name at the end of this form I understand and agree to this all the terms below.
2. A psychological or psychiatric evaluation may be performed before this agreement can go into effect, or at any time Dr. Zahl feels it is necessary, and/or if Dr. Zahl refers me to an addiction specialist for a second opinion I agree to be so evaluated.
3. I agree to random drug testing at the initiation of treatment, and whenever Dr. Zahl feels necessary to monitor the effects of these medications or check for compliance.
4. I must return to be seen by Dr Zahl at least 28 days, or as he directs. If I have not been seen in a month, or if I missed a scheduled appointment this agreement is voided.
5. I am expected to inform his office of any new medications or medical conditions, and of any adverse affects experienced from any of the medications that I take.
6. I know that the Buprenorphine Product prescribed for me may not be shared, sold, traded, exchanged for for money, goods, services, etc. or otherwise permit others to have access to these medications.
7. I agree to keep these medications in a secure place preferably a safe. Since the drugs may be hazardous or lethal to a person that is not tolerant to its affects, especially a child or pet, I must keep them out of the reach of other people or pets.
8. Prescriptions and bottles of these medications may be sought by individuals with chemical dependency and should be closely safeguarded. It is expected that you will take the highest possible degree of care with your medication and prescription. They should not be left where others might see or otherwise have access to them. You will not attempt to get additional buprenorphine from another physician or individual
9. Dr Zahl, my prescribing physician has permission to discuss all diagnostic and treatment details with a dispensing pharmacist or other professionals or clinics/hospitals who provide my health care.
SUBOXONE CONSENT TO RELEASE INFORMATION: Consent to Release of Information Under Title 42, Part 2, Code of Federal Regulations
The privacy and confidentiality of individually identifiable drug or alcohol treatment information is protected by SAMHSA confidentiality regulation Title 42, Part 2 of the Code of Federal Regulations (42 C.F.R. Part 2). This regulation requires that physicians providing opioid addiction treatment obtain signed patient consent before disclosing individually identifiable addiction treatment information to any third party. On the next part is a consent form containing all the data elements required by 42 C.F.R. Part 2.
I authorize Dr. ZAHL OR STAFF to disclose any information needed to confirm the validity of my prescription and for submission for payment for the prescription to the dispensing pharmacy to which I present my prescription or to which my prescription is called/sent/faxed, as well as to third party payors to assure that the pharmacy of the validity of the prescription, so it can be legally dispensed, and for payment purposes.
This consent is subject to revocation at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it.
If not previously revoked, this consent will NEVER terminate
(c) Expired, deficient, or false consent. A disclosure may not be made on the basis of a consent which: (1) Has expired; (2) on its face substantially fails to conform to any of the requirements set forth in paragraph (a) of this section; (3) is known to have been revoked; or (4) is known, or through a reasonable effort could be known, by the individual holding the records to be materially false. (Approved by the Office of Management and Budget under control number 0930//0099.)
Notice to accompany disclosure: Each disclosure made with the patient's written consent must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (Title 42, Part 2, Code of Federal Regulations [42 C.F.R. Part 2]). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the individual to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
I have read and understand these details about buprenorphine treatment. By entering my name below, and submitting, I wish to be treated with buprenorphine and attest that I understand the terms of this agreement and will abide by them.
I also Consent to Release of Information Under Title 42, Part 2, Code of Federal Regulations as described abobve.
enter your full name
WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST