Informed Consent & Treatment Agreement
Informed Consent & Treatment Agreement

Please fill out the following form before your treatment appointment

As a participant in buprenorphine treatment in the On Demand Counseling Program, I understand and voluntarily agree that:

I will keep (and be on time for) all my scheduled appointments with the doctor and other members of the treatment team.

I will participate in individual counseling, 12-step recovery programs, or other types of treatment that I am asked to participate in.

I will keep the medicine safe, secure, and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment.

I will take my medication as instructed and not change the way I take it without first talking to the doctor or another member of the treatment team.

I will tell the doctor or another member of the treatment team if I stop my treatment for any reason. I understand that I will need to plan ahead for any surgery or other medical procedures for which I may need medicines for pain.

I will not call between appointments, or at night or on the weekends looking for refills. I understand that prescriptions will be filled only during scheduled office visits with the treatment team.

I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.

I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped.

I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.

I will sign a release form to let the doctor speak to all other doctors and counselors that I see.

I will tell the doctor about all other medicines that I take, and let him or her know right away if I have a prescription for a new medicine.

I will not get any opioid pain medicines or other medicines that can be addictive such as benzodiazepines (Klonopin, Xanax, and Valium) or stimulants (Ritalin, Amphetamines) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekends.

I will not use illegal drugs such as cocaine, marijuana, or amphetamines while taking buprenorphine. I understand that if I do, my treatment may be stopped.

I will not take any prescribed medication that can be addictive, such as benzodiazepines, stimulants, or opioid pain medicines, without the approval of the physician prescribing buprenorphine.

I will come in for drug testing and counting of my pills. I understand that I must make sure the office has current contact information in order to reach me, and that any missed tests will be considered positive for drug use.

I understand that I may lose my right to treatment in this office if I break any part of this agreement.

Buprenorphine is a medication used to treat people with addiction to opioids, such as heroin, oxycodone, or hydrocodone. Buprenorphine is an opioid that can be used to replace the drugs you are abusing, to prevent the withdrawal sickness and help you stop abusing drugs. Like other opioids, after taking buprenorphine for a while, you will fee withdrawal sickness if you stop taking it suddenly.

Buprenorphine is used to treat opioid addiction, and does not directly help with abuse of alcohol or other drugs such as cocaine or amphetamines.

Buprenorphine treatment is flexible and can last as long as is needed to help prevent relapse to drug use. Each patient will plan how long to be in treatment with the doctor. When a patient and doctor agree that it is time to decrease the medication, the dose will be decreased slowly to help prevent withdrawal sickness.

Buprenorphine lasts a long time in the body and should be taken only once per day, unless otherwise instructed by the physician or member of the treatment team.

Buprenorphine treatment is a tool to help patients recover from opioid addiction, but taking this medication alone is not considered enough treatment to help patients get better, and patients will be required to participate in other forms of treatment such as counseling and IOP.

Buprenorphine may make you constipated, or feel tired or sleepy. You may not be able to drive a car or operate machinery while taking this medicine. If you are having any side effects from the medicine, you must notify the doctor immediately.

This medicine may hurt the liver. Blood tests will be done to make sure you do not have liver problems from the medicine.

If you take this medicine with alcohol or any medicine or drug that causes sleepiness, you could become very sick or die. Taking sedatives such as Klonopin, Valium, or Xanax (or any benzodiazepine) can be dangerous for people taking buprenorphine and should never be done without the permission of your doctor.

If other people take buprenorphine when it is not prescribed for them, they could become very sick or even die, especially children. To participate in buprenorphine treatment, patients must be able to keep this medication locked up, in a cabinet or a lock box, so children cannot get to it. If a child or other person takes your medication, you must call 911 immediately.

Taking lower doses of the medication will decrease the chances of having side effects or other problems with buprenorphine. Patients should always work with the doctor to find the lowest dose of the medicine that helps.

If you take buprenorphine while you have other opioid medications such as oxycodone, hydrocodone, or methadone in your body, you may suffer severe withdrawal sickness. All patients must tell the doctor if they are taking any other opioid drugs or medications.

This medicine will block the effect of opioid pain medications, including medicines given in emergencies and
after surgery. Notify all physicians that you are taking this medication. Notify your physician immediately if you need to have surgery or any medical or dental procedure so you can plan ahead for pain medication. Other doctors may not know about this medicine, so carry the buprenorphine treatment information card at all times.

Buprenorphine Treatment Program Statement

At On Demand Counseling, we are making a commitment to work with you in your efforts to get better. To help you in this work, we agree that:

We will help you schedule regular appointments for medicine refills. If we have to cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment

We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having bad side effects.

We will keep track of your prescriptions and test for drug use regularly to help you feel like you are being monitored well.

We will help connect you with counseling, 12-step programs, and other forms of treatment to help you with your recovery work.

We will help you set treatment goals and monitor your progress in achieving those goals.

We will issue prescriptions to be filled at the pharmacy of your choice. In rare situations, the prescription may be called into the pharmacy by phone by appropriately designated staff.

We will work with any other doctors you are seeing and provide education and information to them about buprenorphine so that they can treat you safely and effectively.

We will include anyone from your family in your treatment if you want them to participate and feel that it would be helpful to have them be a part of it.

We will work with you to make sure you get safe and appropriate pain treatment when needed.

We will work with you to help you stop using other drugs, such as cigarettes, alcohol, and cocaine.

We will work with your medical insurance providers to make sure you do not go without medicine because of paperwork or other things they may ask for.

When it is time to decrease the dose of the medicine, we will work with you to decrease it slowly so that you do not feel a lot of withdrawal symptoms and to help make sure you do not start to use drugs again.

Provider Statement:
I have reviewed the above information with this patient and believe they understand what buprenorphine treatment involves, including potential risks and benefits.