I FIRST AND LAST NAMEagree to receive opioid use disorder treatment with Buprenorphine from New Path Medical Center during my pregnancy, as recommended by national addiction treatment guidelines. My obstetrician will provide my prenatal care. It is my responsibility to keep all prenatal visit appointments as well as all appointments scheduled with Dr. Burton. I have met with Dr. Burton at New Path Medical Center, she has discussed with me and I understand all of the current known risks and benefits of taking Buprenorphine during my pregnancy   INITIALS   

I have been informed that the federal Food and Drug Administration (FDA) has NOT approved the use of Buprenorphine for the treatment of opioid addiction in pregnant women. Whereas, Methadone has been approved for the treatment of opioid addiction during pregnancy and there is 40 years of experience showing methadone treatment to be safe and effective during pregnancy. Therefore, it is currently believed that Methadone is safer than Buprenorphine for the treatment of opioid addiction during pregnancy. I understand that New Path Medical Center does NOT currently offer methadone treatment at this time and that I am free to seek that treatment elsewhere.   INITIALS   

Although small research studies have been completed in Europe and research is now being conducted in the United States on the effects of Buprenorphine on pregnant women and their unborn children, currently there is too little information available to say that Buprenorphine is safe during pregnancy.   INITIALS   

I understand that possible problem of taking any opioid [heroin, methadone, or buprenorphine] during pregnancy is that after birth the child may suffer withdrawal syndrome called Neonatal Abstinence Syndrome. Babies with Neonatal Abstinence Syndrome may suffer from sleep disturbances, feeding difficulties, tremor, sneezing, irritability, vomiting, weight loss, and seizures. A large proportion of these children will require hospitalization, often for long periods of time.    INITIALS   

I understand the currently known risks and benefits of this treatment and have decided to take Buprenorphine. I understand that medical knowledge on the actual or potential risks of Buprenorphine on pregnant women and unborn children is not at all certain. I accept the responsibility for this decision for myself and that of my unborn child.    INITIALS   

I understand to go to my closest Emergency Department in the event that any complications arise with my pregnancy. I will also to notify my Obstetrician immediately. Further, I understand that it is MY RESPONSIBILITY to make known to ALL HEALTHCARE PROVIDERS that I may see during my pregnancy that I am taking Buprenorphine.     INITIALS   

On behalf of myself and my unborn child, I hereby release and agree to hold harmless, the program, the prescribing doctor and the program’s officers, directors, agents, and employees from any liability of any kind which may arise in connection with my taking buprenorphine during the duration of my pregnancy.    INITIALS