Agreement for Treatment with Buprenorphine/Naloxone

I understand that buprenorphine/naloxone is a medication to treat opiate addiction (for example: heroin, prescription opiates such as oxycodone, hydrocodone, methadone Buprenorphine/naloxone contains the opiate narcotic analgesic medication, buprenorphine, and the opiate antagonist drug, naloxone, in a 4 to1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication.

Injection of buprenorphine/naloxone by a person who is addicted to opiates will produce severe opiate withdrawal.

I agree to keep appointments and let staff know if I will be unable to show up as scheduled

I agree to report my history and my symptoms honestly to my physician, nurses, and counselors involved in my care. I also agree to inform staff of all other physicians and dentists who I am seeing; of all prescription and non prescription drugs I am taking; of any alcohol or street drugs I have recently been using; and whether I have become pregnant or have developed hepatitis.

3.I agree to cooperate with witnessed urine drug testing whenever requested by medical staff, to confirm if I have been using any alcohol, prescription drugs, or street drugs.

I have been informed that buprenorphine is a narcotic analgesic, and thus it can produce a "high"; I know that taking buprenorphine/naloxone regularly can lead to physical dependence and addiction, and that if I were to abruptly stop taking buprenorphine/naloxone after a period of regular use, I could experience symptoms of opiate withdrawal. I also understand that combining buprenorphine/naloxone with benzodiazepine (sedative or tranquilizer)

medications (including but not limited to Valium, Klonopin, Ativan, Xanax, Librium, Serax) has been associated with severe adverse events and even death. I also understand that I should not drink alcohol with buprenorphine/naloxone since it could possibly interact with buprenorphine/naloxone to produce medical adverse events such as reduced breathing or impaired thinking. I agree not to use benzodiazepine medications or to drink alcohol while taking buprenorphine/naloxone and I understand that my doctor may end my treatment with buprenorphine if I violate this term of the treatment agreement.

5.I have been informed that buprenorphine/naloxone is to be placed under the tongue for it to dissolve and be absorbed, and that it should never be injected. I have been informed that injecting buprenorphine/naloxone after taking buprenorphine/naloxone or any other opiate regularly could lead to sudden and severe opiate withdrawal.

I have been informed that buprenorphine/naloxone is a powerful drug and that supplies of it must be protected from theft or unauthorized use, since persons who want to get high by using it or who want to sell it for profit, may be motivated to steal my take-home prescription supplies of

7.I have a means to store takehome prescription supplies of buprenorphine/naloxone safely, where it cannot be taken accidentally by

children or pets, or stolen by unauthorized users. 1 agree that if my buprenorphine/naloxone pills are swallowed by anyone besides me, 1 will call 911 or Poison Control at 1-800-222-1222 immediately and I will take the person to the doctor or hospital for treatment.

8.I agree that if my doctor recommends that my home supplies of buprenorphine/naloxone should be kept in the care of a responsible member of my family or another third party, I will abide by such recommendations.

I will be careful with my take-home prescription supplies of buprenorphine/naloxone, and agree that I have been informed that if I report that my supplies have been lost or stolen, that my doctors will not be requested or expected to provide me with make-up supplies. This means that if I run out of my medication supplies it could result in my experiencing symptoms of

opiate withdrawal. Also, I agree that if there has been a theft of my medications, I will report this to the police and will bring a copy of the police report to my next visit.

10.I agree to bring my bottle of Buprenorphine/naloxone in with me for every appointment with my doctor so that remaining supplies can be counted.

11.I agree to take my Buprenorphine/naloxone as prescribed, to not skip doses, and that I will not adjust the dose without talking with my doctor about this so that changes in orders can be properly communicated by to my pharmacy.

12.I agree that I will not drive a motor vehicle or use power tools or other dangerous machinery during my first days of taking Buprenorphine/naloxone, to make sure that I can tolerate taking it without becoming sleepy or clumsy as

13.I agree that I will arrange transportation to and from the treatment facility during my first days of taking Buprenorphine/naloxone so that I do not have to drive myself to and from the clinic or hospital

14.I want to be in recovery from addiction to all drugs, and I have been informed that any active addiction to other drugs besides heroin and other opiates must

be treated by counseling and other methods. I have been informed that buprenorphine, as found in Buprenorphine/naloxone, is a treatment designed to treat opiate dependence, not addiction to other classes of drugs.

15.I agree that medication management of addiction with buprenorphine, as found in Buprenorphine/naloxone, is only one part of the treatment of my addiction, and I agree to participate in a regular program of professional counseling while being treated with Buprenorphine/naloxone.

16.I agree that professional counseling for addiction has the best results when patients also are open to support from peers who are also pursuing recovery.

17.I agree to participate in a regular program of peer/self-help while being treated with Buprenorphine/naloxone.

18.I agree that the support of loved ones is an important part of recovery, and I

agree to invite significant persons in my life to participate in my treatment

19.I agree that a network of support, and communication among persons in that network, is an important part of my recovery. I will be asked for my authorization, to allow telephone, email, or face-to-face contact, as appropriate, between my treatment team, and outside parties, including physicians, therapists, probation and parole officers, and other parties, when the staff has

decided that open communication about my case, on my behalf, is necessary.

20.I agree that I will be open and honest with my counselors and inform staff about cravings, potential for relapse to the extent that I am aware of such, and

specifically about any relapse which has occurred -before a drug test result shows it.

21.I have been given a copy of clinic procedures, including hours of operation, the clinic phone number, and responsibilities to me as a recipient of addiction treatment services, including buprenorphine treatment with Buprenorphine/naloxone.