YOU HAVE THE RIGHT AND THE OBLIGATION TO MAKE DECISIONS CONCERNING YOUR HEALTH CARE.
This form acknowledges your consent to treatment. Your counselor can provide you with the necessary information and advice, but because this affects you, the decision-making or treatment planning process requires your participation. Please feel free to ask any questions or to ask your counselor to clarify areas of your program if it is not understood.
To assist you in making an informed decision concerning your treatment, your substance abuse counselor will explain the following to you:
1. Kū Aloha Ola Mau services offered, i.e. educational sessions, process groups, skill building activities and alternative forms of treatment available, their benefits and risk, and the benefits and risks of no treatment;
2. Anticipated results and benefits of the proposed treatment;
3. Risks and complications involved in the proposed treatment;
4. The time period this consent applies to;
5. The right to ask questions about the proposed treatment and have them answered;
6. The right to secure a second opinion prior to the giving of consent; and
7. The right to withdraw consent at any time.
Possible risks and benefits of treatment in the Kū Aloha Ola Mau OTP are:
1. You will be asked to share personal experiences with your counselor and other participants at times. While you are encouraged to share only to the extent you feel comfortable, some people find this to be difficult and disturbing while others find it to be a positive and liberating experience.
2. You will be provided with methadone that requires a stabilization period you may experience some physical discomfort and/or side effects during this period. The physician and your counselor will go over these with you. There are some medications listed in the Patient Fact Sheet that are not recommended for you to take while you are on methadone as they may create withdrawal symptoms. Methadone provides people with the opportunity to discontinue other opiate use and lead productive lives.
3.There is a need for a medical withdrawal from methadone. You will not be comfortable with abrupt discontinuation of treatment. Kū Aloha Ola Mau will provide you with a mutually agreed upon withdrawal schedule should you desire a voluntary detox off the program.
4. Methadone pharmacotherapy is not designed to address addiction to other substances such as cocaine, benzodiazepines, and so forth. However, the counseling part of the program will address addiction issues - - including alcohol, tobacco & other drugs - - intended to reduce the risk of multiple addictions or developing new addictions.
5. There may be a need to contact your primary care physician or specialist to coordinate your care and ensure quality care. Some physicians do not understand or support opioid treatment therapies and may advise you against continuing on the program. Other physicians have seen the benefits and have been able to provide excellent coordination on behalf of the patients.
6. If you are a female on methadone, you will be able to go full term without using other opiates. Your baby will go through the withdrawal process if your dose is high. However, it can be successfully and safely treated if your care is coordinated by your ob/gyn. The main side effect experienced may be low birth weight.
Once given, your informed consent to treatment may be withdrawn at any time by stating such intention to your counselor. Otherwise, your informed consent will expire when your treatment has been terminated. Refusal to sign or withdrawal of consent may result in termination of services and discharge from the program.
By signing below, you agree that:
1.You understand this form;
2.You have received all the information you want about your treatment plan;
3.You have given us your permission to carry out the treatment plan;
4.You have been given a copy of your rights as a consumer; and
5.You have been given a copy of the Methadone Fact Sheet that includes program rules and regulations.
Time period to which this informed consent applies: