Acknowledgement of Practice Policies and Consent to Participate in Opioid Use Disorder Treatment

I understand that the objective of treatment is to support my health, wellbeing and personal goals, balanced with the needs and safety of other patients here and the wider community. I have the right to be treated with dignity and respect, and I am encouraged to inform the practice staff of any instance where I feel my treatment has fallen short of standards. Staff have the professional responsibility to maintain confidentiality in accordance with applicable laws and regulations. I also agree not to share any information about other clients with anyone other than program staff.

I understand that medications can be harmful if not taken as prescribed. Buprenorphine can be fatal to children, adults, and pets if not taken as prescribed. I am fully responsible for safeguarding any medication I given to take home. The medication should be in a lockbox in a safe place. I agree that if my medications are swallowed by anyone besides me, I will immediately call 911 or Poison Control (1-800-222-1222).

I understand that, like all medications, medications for opioid use disorder have benefits, risks,and sideeffects.Theywillproducephysicalopioiddependenceandwithdrawalif discontinued. Possible side effects, as well as alternative treatments and their risks and benefits,havebeenexplainedtome.Takingbuprenorphineincombinationwithalcohol, benzodiazepines like Xanax (“bars”), Klonopin (“pins”), Valium, or Ativan; clonidine (“dines”); promethazine (“finnegans”); and other opioids can result in serious side effects, including death. If the medical staff here is concerned about the safety of prescribing buprenorphine while I am taking these or any other substances, it may result in modification to my treatment.

I understand that it is important for me to inform any medical and psychiatric provider who may treat me that I am receiving treatment for Opioid Use Disorder. In this way, the provider will be aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my medical treatment or my recovery. I understand that I may be asked to sign a release so that the providers here can communicate with my other prescribers. Failure to do so may result in modifications to the treatment I receive here.

While receiving treatment for addiction I agree not to accept or fill any prescription for opioids or benzodiazepines without first obtaining permission from the medical staff here. If I take or am given any such medicines in an emergency I will report this to the treatment team and prescriber within 24 hours and bring the medication bottle with any remaining medication promptly to the treatment program.

For patient and community safety, medication call-backs and verification are standard practice in addiction treatment. I agree to bring in all of my medications when asked, even if they are not prescribed or dispensed in this practice. If asked, I must return all empty medication packaging when I come in for treatment.

Lost prescriptions or medication are serious issues and may result in modifications to the treatment received from this practice. If my medication is lost or stolen this practice may not be able to arrange for make-up supplies. I agree that if there has been a theft of my medication, I will report this to the police and will bring a copy of the police report to my next clinic visit.

I understand that blood testing for tuberculosis (TB), HIV, hepatitis, syphilis, and other communicable diseases is a standard part of addiction treatment. I agree to periodic and random toxicology (drug) testing in order to monitor my drug use and medical treatment. This
may be done through a urine or saliva test. Refusing to provide a test specimen will be documented and addressed per practice protocol.

I understand that I may withdraw voluntarily from this treatment plan and discontinue the use of these medications at any time. If I choose this option, I understand I will be offered medically supervised withdrawal, and may continue receiving other medical care in this practice, as indicated.

I understand that counseling is an important part of treatment for many patients. I agree to work with program staff to develop a counseling schedule that fits my treatment needs and preferences.

I understand that this program participates in the Encounter Notification Service from CRISP, the Health Information Exchange for Maryland and DC. Information on this service, including information on how to opt out of information sharing, is available on request.

I understand that in the case of a life-threatening emergency, program staff may contact the individual(s) I designate as an emergency contact.

For women of childbearing age: Pregnant women treated with methadone or buprenorphine have better outcomes than pregnant women not in treatment who continue to use opioid drugs. Newborns of mothers who are receiving methadone o r buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal opioid withdrawal syndrome). This is less likely with buprenorphine. The delivery hospital may require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal symptoms. Some babies may also need medication to stop withdrawal. If I am or become pregnant, I understand that I should tell the medical staff here right away so I can receive or be referred to prenatal care. I understand that medical staff will discuss with me how to maximize the health of my pregnancy while I am taking methadone or buprenorphine.
I authorize and give voluntary consent to this practice to recommend and prescribe medications to treat my opioid use disorder. I have been informed of treatment risks, benefits, and alternatives, and have had an opportunity to get any questions I have answered by program staff and medical providers.