familymedicinetennessee.com - New Patient OBOT 2023

New Patient OBOT 2023

Once a thorough patient assessment has been performed, a formal diagnosis of either opioid dependence or abuse can be made. A substance dependence or abuse diagnosis, according to current DSM-IV diagnostic schema, is based on clusters of behaviors and physiological effects occurring within a specific time frame. A diagnosis of dependence always takes precedence over that of abuse, i.e., a diagnosis of abuse is made only if DSM-IV criteria for dependence have never been meet.

DEPENDENCE
3 or more in a 12-month period

ABUSE
1 or more in a 12-month period
(symptoms must never have met criteria for dependence)

Tolerance (marked increase in amount; marked decrease in effect)
Characteristic withdrawal symptoms ; substance taken to relieve withdrawal
Substance taken in larger amount and for longer period than intended
Persistent desire or repeated unsuccessful attempt to quit
Much time/activity to obtain , use , recover
Important social, occupational ,or recreational activities given up or reduced
Use continues despite knowledge of adverse consequences(e.g., failure to fulfill role obligation, use when physically hazardous)

Recurrent use resulting in failure to fulfill major role obligation at work, home, or school
Recurrent use in physically hazardous situations
Recurrent substance related legal problems
Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by substance

In using the DSM-IV criteria, one should specify whether substance dependence is with physiologic dependence (i.e., there is evidence of tolerance or withdrawal) or without physiologic dependence (i.e., no evidence of tolerance or withdrawal). In addition, patients may be variously classified as currently manifesting a pattern of abuse or dependence or as in remission. Those in remission can be divided into four subtyped-full, early partial, sustained, and sustained partial-on the basis of whether any of the criteria for abuse have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (e.g., methadone maintenance) or for those living in a controlled drug-free environment.

*criteria from American Psychiatric Association (2000).Diagnostic and Statistical Manual of Mental
Disorders, fourth Edition, text Revision. Washington, DC, American Psychiatric Association page 197.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorder, Text Revision,
Fourth Edition, (copyright 2000). American Psychiatric Association

DSM-IV CRITERIA FOR OPIOID DEPENDENCE DIAGNOSIS: WORKSHEET
Patient Name:

Diagnostic Criteria*(Dependence required meeting 3 or more criteria)

	Meets Criteria	Notes/Supporting information
(1) Tolerance, as defined by either of the following: (a) Need for markedly increased amount of the substance to achieve intoxication desired effect
(b) Markedly diminished effect with continued use of the same amount of the substance
(2) Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome
(b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) The substance id often taken in larger amount or over a longer period of time than intended
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects
(6) Important social, occupational, or recreational activities are giving up or reduced because of substance use
(7) The substance use id continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

Physician Signature

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APPROPRIATE USE CHECKLIST

Suboxone (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet /films/ Bunavil / Zubsolv
As a healthcare provider who prescribes Suboxone (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet /films/ Bunavil / Zubsolv. You may find this checklist useful reminder of the safe use conditions and monitoring requirements to be addressed during each patient appointment. These include: 1) understand and reinforcement of safe use conditions, 2) the importance of psychosocial counseling, and 3) screening and monitoring patients to determine progress toward treatment goals.

If a patient continues to abuse various drugs or is unresponsive to treatment, including psychosocial intervention, it is important that you assess the need to refer the patient to a specialist and/or more intensive behavioral treatment environment.

Measurement to Ensure Appropriate Use

	Intake/Induction	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5	Visit 6	Visit 7
DATE:

Measurement to Ensure Appropriate Use(INDUCTION)

	Intake/Induction	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5	Visit 6	Visit 7
Verified patient meets diagnostic criteria for opioid dependence
Discussed risks described in professional labeling and Medication Guide with patient
Explained or reviewed conditions of safe storage of medication
provided induction doses under appropriate supervision
Prescribed limited amount of medication at first visit
Scheduled next visit at interval commensurate with patient stability -Weekly or more frequent visit are recommended for the first month

APPROPROATE USE CHECKLIST

Measurement to Ensure Appropriate Use

	Intake/Induction	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5	Visit 6	Visit 7
DATE:

Measurement to Ensure Appropriate Use (MAINTENANCE)

	Intake/Induction	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5	Visit 6	Visit 7
Assessed and encouraged patient to take medication as prescribed - Consider pill count/dose reconciliation
Assessed appropriateness of dosage • Suboxone Films • Buprenorphine tablet • Subutex • Bunavil • Zubsolv
Assessed whether patient is receiving the psychosocial support considered necessary
Assessed whether benefits of treatment with medication outweigh risk associated with medication
Assessed whether patient is making adequate progress toward treatment goals • Conduct urine drug screens as appropriate to assess use of illicit substances • Consider referral to more intensive forms of treatment for patients not making progress
Scheduled next visit at interval commensurate with patient stability • Weekly or more frequent visit are recommended for the first month

PROBLEM LIST – CURRENT MEDICTIONS
Pharmacy Name:
Pharmacy Number:
Please enter a valid phone number.
Patient D.O.B.:

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PRESCRIPTION LOG
*IMPORTANT NOTICE:

The recommended recordkeeping information is for reference only; you (the physician) should update the records or recordkeeping practice to be consisted with the most current State and Federal regulations. The material provided in this document does not constitute legal advice. This document is not a substitute for the advice of legal counsel and does not address all of the factual, legal or regulatory issues arise in connection with a DEA visit.

Medication Dosing Record
Medication

Medication

	Describe withdrawal symptoms/side effects below
Strength (mg):
Strength (mg):
Strength (mg):
Total Dose (mg):

* Patient should be instructed to keep their medication in a secure place, out of the sight and reach of children. Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. Patients should be advised that if a child is exposed to the medications, medical attention should be sought immediately.

Affordable & Restorative Health Care

Winston Griner Sr. M.D
Explanation of Treatment

When you leave the office, the doctor will likely give you a prescription that will last you until your next appointment which will be in 28 days. The doctor may also want to discuss counseling with you, since medication plus counseling has been shown to produce better results. At the same time, your doctor may suggest enrolling in the Here to Help Program, which can provide you with an added support system. Your doctor will ask you to keep a record of any medication you take at home to control withdrawal symptoms. You will also receive instruction on how to contact your doctor in an emergency as well as additional information about treatment. Please bring lab, diagnostic history & physical, last 2 visit or discharge pharmacy print of last
Checklist for First Visit:

Arrive experiencing moderate opioid withdrawal symptomsArrive prepared to give a urine sample for screeningBring completed formsBring all medication bottles/ wrappers.Co-pay/Full fee due at the time of visit (Cash, Debit/Credit Card or Money Order)On time (Affordable and Restorative Healthcare Web site complete forms and print out)
Please see your doctor or pharmacist for full product information for your medicine

Suboxone (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet /films/ Bunavil / Zubsolv

Intake

You will be given a comprehensive substance dependence assessment, as well as evolution of mental status and physical exam. The pros and cons of the medication, SUBOXONE, will be presented. Treatment expectations, as well as issues involved with maintenance versus medically supervised withdrawal will be discussed.

Induction

You will be switched from your current opioid (heroin, methadone or prescription painkillers) on to SUBOXONE.at the time of induction, you will be asked to provide a urine sample to confirm the presence of opioids and possibly other drugs. You must arrive for the visit experiencing mild to moderated opioid withdrawals symptoms. Arrangements will be made for you to receive your first doses prescription /you are taking buprenorphine/naloxone. Your response to the initial dose will be monitored. You may receive additional medication, if necessary, to reduce withdrawal systems.

Since an individual’s tolerance and reaction to SUBOXONEFILMS/ BUNAVIL / ZUBSOLV vary, daily appointments may be scheduled and medications will be adjusted until you no longer experience withdrawal symptoms or cravings. Urine drug screening is typically required for all patients at every visit during this phase. Intake and induction may both occur at the first visit, depending on your needs and your doctor’s evaluation.

Stabilization

Once the appropriate are of SUBOXONEFILMS/ BUNAVIL / ZUBSOLV is established, you will stay at this does until steady blood levels are achieved. You and your doctor will discuss your treatment options from this point forward.

Maintenance

Treatment compliance and progress will be monitored. Participation in some form of behavioral counseling is strongly recommended to ensure best chance of treatment success. You are likely to have scheduled appointments on a weekly basis, however, if treatment progress is good and goals are met, monthly visit will eventually be considered sufficient. The maintenance phase can last from weeks to year-the length of treatment will be determined by you and your doctor, and, possibly, your counselor. Your length of treatment will vary depending on you individual needs.

Medically Supervised Withdrawal

As your treatment progresses ,you and your doctor may eventually decide that medically supervised withdrawal is an appropriate option for you.in this phase, your doctor will gradually taper your SUBOXONEFILMS/ BUNAVIL / ZUBSOLV dose over time, taking care to see that you do not experience any withdrawal symptoms or cravings. (i.e.: 2 one day 1 ¾ next day then 2 next day 1 ¾)

Explanation of First Visit
Your first visit is generally the longest, and may last anywhere from 1 to 4 hours. When preparing for your first visit, there are a couple of logistical issues you may want to consider:
- You may not want to return to work on the day of your visit-this is very normal, so just plan
  accordingly.
- Because the medication can cause drowsiness and slow reaction times, particularly during the first few weeks of treatment, you may want to make arrangements for a ride home.
It is very important to arrive for your first visit already experiencing moderate opioid withdrawal symptoms. If you are in withdrawal, the medicine is supposed to help lessen the symptoms. However, if you are not in withdrawal, the medicine will “override” the opioid already in your system, which will cause severe withdrawal symptoms.

The following guidelines are provided to ensure you re in withdrawal for the visit.(if this concerns you, it may help to schedule your first visit in the morning ; some patients find it easiest to skip what would normally be their first dose of the day)
- No methadone or long-acting painkillers for at least 24 hours
- No heroin or short-acting painkillers for at least 4 to 6 hours
Bring ALL medication bottles with you to your first appointment.

Before you can be seen by the doctor, all of the paperwork your doctor provided must be completed. If your doctor provided the paperwork to you prior to this visit, bring it completed or arrive about 30 minutes early to fill it out.

Urine drug screening is a regular procedure of treatment, because it provides physicians with important insight into your health and your treatment. Your first visit will include urine drug screening, and may also entail an alcohol test and blood work. If you haven’t had a recent physical exam, your doctor may require one. To help ensure that this medicine is the best treatment option for you, your doctor will perform a substance dependence assessment and mental status evaluation. Lastly, you and your doctor will discuss the medicine and your expirations of treatment.

After this portion of your visit is completed, will write a prescription to be giving to a pharmacy. Your doctor may have you fill the prescription at the pharmacy. If any problems occur go to the emergency room

Once you take your fist dose, you should begin to feel better within 30 minutes. It’s important that you are honest about how you are feeling during induction+ so your doctor can find the appropriate does for you.

+ SUBOXONEFILMS/ BUNAVIL / ZUBSOLV (buprenorphine and naloxone) sublingual films (CIII) is not indicated for induction

Frequent Asked Questions
Risk Evaluation and Mitigation Strategy (REMS)

WHAT IS A RISK EVALUATION AND MITIGATION STRATEGY?

A REMS is a strategy to manage a know or potential risk associated with a drug. A REMS can include among other strategies, a medication Guide a communication Plan and elements to assure safe use.

IS THERE A REMS FOR SUBOXONEFILMS/ BUNAVIL / ZUBSOLVREMS?
1. The goals of the REMS for SUBOXONEFILMS/ BUNAVIL / ZUBSOLV are to:
  Minimizes the risk of accidental overdose ,misuse, and abuse
2. Inform physician ,pharmacists and patient of the serious risk associated with the use of
  SUBOXONE
WHAT IS MY ROLE WITH REGARDS TO THE REMS FOR SUBOXONE?

To meet the requirements of the REMS and to ensure the benefits of prescribing SUBOXONEFILMS/BUNAVIL / ZUBSOLV to a patient outweigh the risk of accidental overdose, misuse and abuse ,physicians should take the following measures and documents action taken with patient to ensure safe use conditions.
- Verify patient meets diagnostic criteria for opioid dependence
- Discuss the risk associated with SUBOXONE, including those described in the medication guide
- Provide induction doses under appropriate supervision
- Prescribe a limited of medication during the initial stage of treatment
- Explain how to safely store the medication
- Schedule patient appointment commensurate with patient stability weekly or more frequent visit recommended for the first month
- Consider pill Count/dose reconciliation
- Assess whether patient is receiving counseling / psychosocial support considered necessary for treatment
- Assess whether patient is making progress toward treatment goal including as appropriate,
  urine toxicology testing
- Continually assess appropriateness of maintenance dose
- Continually assess whether or not benefits of treatment outweigh the risk
As part of the REMS, physicians prescribing SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for opioid dependence will be provided with an appropriate use checklist to document safe use condition and clinical monitoring of each patient. This can be retained in the records of each patient.

This REMS does not patients admitted to opioid treatment dispensed to patient admitted to opioid treatment programs under 42 CFR part 8 because the care of these patient is subject to specific requirements under those regulations.
Frequently Asked Questions: Patients

SUBOXONE (buprenorphine HCI/naloxone HCI dehydrate) Sublingual tablet films/ bunavil / zubsolv,

1. Why do I have to feel sick to start the medication for it to work best?
When you first dose of SUBOXONE, if you ready have a high levels if another opioid in your system, the SUBOXONE will compete with those opioid molecules and replace them at the receptor sites. Because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV has a milder opioid effect than full agonist opioid, you may go into a rapid opioid withdrawal and feel sick, a condition which is called “precipitated withdrawals.”
By already being in mild to moderate withdrawal when you take your first does of SUBOXONE, the medication will make you feel noticeably better, not worse.

2. How does SUBOXONEFILMS/ BUNAVIL / ZUBSOLV work?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV bind to the same receptors as other opioid drugs. It mimics the effects of other opioids by alleviating carving and withdrawal symptoms. This allows you to address the psychosocial reason behind your opioid use.

3. When will I start to feel better?
Most patient feel a measurable improvement by 30 minutes to an hour, with the full effects clearly noticeable after about 2 hour.

4. How long will SUBOXONEFILMS/ BUNAVIL / ZUBSOLV last?
After the first hour, many people say they feel pretty good for most of the day. Responses to SUBOXONEFILMS/ BUNAVIL / ZUBSOLV will vary based on factors such as tolerance and merablism.so each patient’s dosing is individualized. Your doctor may increase your does of SUBOXONEFILMS/ BUNAVIL / ZUBSOLV during the first week to help keep you from feeling sick.

5. Can I go to work right after my first does?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV can cause drowsiness and slow reaction times. These Reponses are more likely over the first few weeks of treatment, when your does is being is being adjusted. During this time, your ability to drive, operate machinery, and play sports may be affected. Some people do go to work right after their first SUBOXONEFILMS/ BUNAVIL / ZUBSOLV machinery, dose; however, many people prefer to take the first and possibly the second day off until they feel better. If you are concerned about missing work, talk with your physician about possible way to minimize the possibility of your taking time off (e.g. Scheduling your induction on a Friday).

6. Is it important to take my medication at the same time each day?
In order to make sure that you do not get sick, it is important to take you medication at the same time each day.

7. If I have more than one tablet (film), do I need to take them together at the same time?
Yes and no- you do need to take your does at one “sittings, “But you do not necessarily need to fit all the tablets under your tongue simultaneously. Some people prefer to take their tablets this way because it faster, but this may not be what works best for you. The most important things is to be sure to take the full daily does you were prescribed, so that your body maintains constant levels of SUBOXONE.

8. WHY DOES Suboxone films/ bunavil / zubsolv need to be placed under the tongue?
There are two large veins under your tongue (you can see them with a mirror). Placing the medication under your tongue allows SUBOXNE to be absorbed quickly and safely though these veins as the tablet dissolves. If you chew or swallow your medication, it will not correctly absorbed as it is extensively metabolized by the liver. Similarly, if the medication is not allowed to dissolve completely, you won’t receive the full effect,

9. Why can’t I talk while the medication is dissolving under the tongue?
When you talk, you move your tongue, which lets the undissolved SUBOXONEFILMS/ BUNAVIL / ZUBSOLV “leak” out from underneath, thereby preventing it from being absorbed by the two veins. Entertaining yourself by reading or watching television while your medication dissolves can help the time to pass more quickly over 20-30 minutes after it dissolves.

10. Why does it sometimes only take 5 minutes for SUBOXONEFILMS/ BUNAVIL / ZUBSOLV to dissolve and other times it takes much longer?
Generally, it takes 5-10 minutes for the tablets to dissolve. However, other factors (the moisture of your mouth) can effect that times. Drinking something before taking your medication is a good way to help the tablet dissolve more quickly.

11. If I forget to take my SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for a day will I feel sick?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV works best when taken every 24 hours; however, it may last longer than 24 hours, so you may not get sick. If you miss your does, try to take it as soon as possible, unless it is almost time for your next dose. If it is almost time for your next dose, just skip the dose you forgot, and take next does as prescribed. Do not take two does at once unless directed to do so by your physician.
On the future, the best way to help yourself remember to take your medication is to start taking it the same time that your perform a routine, daily Activity, such as when you get dressed in the morning .this way, the daily activity will start to serve as a reminder to take your SUBOXONE.

12. What happens if I still feel sick after taking SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for a while?
There are some reasons why you may still feel sick. You may not be talking the medication correctly or the dose may not be right for you. It is important to tell you doctor or nurse if you still feel sick.

13. What happens if I take drugs and then take SUBOXONE?
You will probably feel very sick and experience what is called a “precipitated withdrawal.” Suboxone films/ bunavil / zubsolv competes with other opioids and will displace those molecules form the receptors. Because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV has less opioids effects than full agonist opioids, you will go into withdrawal and feel sick.

14. What happens if I take Suboxone films/ bunavil / zubsolv and then take a drug?
As long as SUBOXONEFILMS/ BUNAVIL / ZUBSOLV is in your body, it will significantly reduce the effects of any other opioids used, because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV will dominate the receptor sites and block other opioids from producing any effect.

15. What are the side effects of this medication?
Some of the most common side effects that patient experience are nausea, headache, constipation ,and body aches and pains. However, most side effects seen with SUBOXONEFILMS/ BUNAVIL / ZUBSOLV appear during the first week or two of treatment, and then generally subside. If you are experiencing any side effects, be sure to talk about it with your doctor or nurse, as s/he can often treat those symptoms effectively until the Qabate on their own.

Patient Treatment Agreement
As a participant in medication treatment for opioid misuse and dependence freely and voluntarily agree
to accept this treatment agreement as follows:

1. I agree to keep, and be on time to, all my scheduled appointment (every 28 day). Call and notify staff of any changes in delay in appointment by talking to staff 24 hours min prior to appointment. Otherwise a penalty of min. $50 for missed appointment or no show     Patient Initials
2. If unable to keep appointment set I agree to give a 24 hour notice and will have to be seen the next day.   Patient Initials
3. Patient are to bring medication wrappers USED AND UNUSED to every visit.   Patient Initials
4. I agree to adhere to the payment policy outline by this office.   Patient Initials
5. I agree to report my history and symptoms honestly to my doctor and the office staff will inform my doctor about any medications (prescription and non-prescription) that I am taking. I will report any changes in my medical history, such as becoming pregnant immediately.   Patient Initials
6. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.   Patient Initials
7. I understand that my medication must be stored safely, where it cannot be taken accidentally by children or pets, or stolen. If anyone else, including a child, takes my medication I will call 911 or poison control at 1-800-222-1222 immediately and transfer to hospital.   Patient Initials
8. I agree not to deal drugs, steal, or conduct any illegal or disruptive activities in or around the doctor office or ever.   Patient Initials
9. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without any recourse for appeal.   Patient Initials
10. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription and may result in termination of care from this office.   Patient Initials
11. I will be careful with my take-home prescription supplies of my medication, if I report that my supplies have been lost or stolen my doctor may not provide me with a make-up supply. But that my doctor has the right to not to.   Patient Initials
12. I understand that at every visit, my doctor will ask me to bring my unused and unused wrappers /bottles supply of medication for a medication count and that I may not get refill if I do not bring my medication with me.   Patient Initials
13. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place, I agree that lost medication will not be replaced regardless of why it was lost.   Patient Initials
14. I agree not to obtain medication from any doctor, pharmacies, or other sources without telling my treating physician.   Patient Initials
15. I understand that mixing this medicine with other medication, especially benzodiazepines (for example, Valium*, Klnopin+ or Xanax++) can be dangerous. I also recognize that several deaths have occurred among person mixing buprenorphine and benzodiazepines (especially if taken outside of a physician using routes of administration other than sublingual or in higher than recommended therapeutic doses.)   Patient Initials
16. I agree to read the medication guide and consult my doctor should I have any questions or experience any adverse events.   Patient Initials
17. I agree to take my medication as my doctor had instructed and not to alter the way I take my medication without first consulting my doctor.   Patient Initials
18. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.(AA,NA,CELEBRATE RECOVORY MEETINGS, SPONSORSHIP AAD CUUMAL USE MENTAL HEALTH ADVISE )   Patient Initials
19. I agree to abstain from ALCOHOL, OPIOIDS, MARIJUANA, and COCAIN AND OTHER ADDITIVE SUSBSTANCES (except nicotine.)   Patient Initials
20. I agree to provide random urine samples and have my doctor test my blood alcohol level.   Patient Initials
21. I UNDERSTAND THAT VIOLATION OF THE ABOVE MAY BE GROUNDS FOR TERMINATION OF TREATMENT.   Patient Initials
Patient Signature

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Beck Anxiety Inventory (BAI)
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

	Not At All	Mildly (But it didn’t bother me much)	Moderately (It wasn’t pleasant at times)	Severely (It bothered me a lot)
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot/cold sweats

BUPRENORPHINE CONSENT TO TREATMENT FORM
Buprenorphine is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Qualified physicians can treat up to 275 patients for opiate dependence. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary.

Buprenorphine itself is an opioid, but it is not as strong an opioid as heroin or morphine. Buprenorphine treatment can result in physical dependence of the opiate type. Buprenorphine withdrawal is generally less intense than with heroin or methadone. If buprenorphine is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, buprenorphine should be discontinued gradually, usually over several weeks or more.

If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of buprenorphine. It you are not in withdrawal; buprenorphine may cause significant opioid withdrawal. You should have a clinical opioid withdraw (COWS) rating of 20-25 before you start Buprenorphine safety for that reason, you should take the first dose in the office and remain in the office for observation. Within a few days, you will have a prescription for buprenorphine that will be filled in a pharmacy.

Some patients find that it takes several days to get used to the transition from the opioid they had been using to buprenorphine. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on buprenorphine, it is expected that other opioids will have less effect. Attempts to override the buprenorphine by taking more opioids could result in an opioid overdose. You should not take any other medication without discussing it with me first.

Combining buprenorphine with alcohol or some other medications may also be hazardous, causing breathing suppression. The combination of buprenorphine with medication such benzodiazepine as Valium, Librium, Ativan etc... has resulted in deaths.

The form of buprenorphine you may be taking is a combination of buprenorphine with a short-acting opiate blocker (naloxone). If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal.

Buprenorphine tablets/films must be held under the tongue until they dissolve completely. Tablets should be crushed and placed under tongue with small amount of warm water and swish and hold in for 30 minutes and not swallow and not Buprenorphine is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Buprenorphine will not be absorbed from the stomach if it is swallowed.
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BUPRENORPHINE INFORMED CONSENT

(including birth defects)
Goals for taking buprenorphine:
Maintain adequate relief opioid craving and other withdrawal symptoms to allow for activities of daily living including those activities necessary to meet the patient’s social, domestic and employment needs.

Proposed duration of use (based on recovery skill development): Indefinite, to be determined by your doctor based on your medical condition and response to treatment. However, the goal is to limit long term use based on the development of coping skills and stabilization of your social and living situation such that the buprenorphine may be tapered off safely with as little risk for relapse as possible. A suggested goal would be to limit treatment with buprenorphine to one year, but this time frame is unique for each patient.

Conditions of buprenorphine management:
Successful buprenorphine management entails employing multiple interventions, including active participation in addiction prevention programs such as AA or NA and the use of psychological coping strategies. A pattern of passive reliance on medications, resistance to counseling and/or addiction prevention programs, or repeated failure to demonstrate the implementation of psychological coping strategies that have been taught to you may lead to discontinuation of buprenorphine and/or referral to another provider or treatment center. Coordination of care between your buprenorphine management physician and other physicians managing your other medical conditions is important for your safety, especially regarding medication management. You agree to provide consent for allowing your buprenorphine management physician to share your buprenorphine management information with your other managing physicians.

Physical dependence will develop with regular use of buprenorphine. Physical dependence means that a withdrawal syndrome will develop if you stop or suddenly reduce the dose of your opioid medication abruptly. The typical withdrawal syndrome from buprenorphine and other opioids includes restlessness, vomiting, diarrhea, muscle aches and severe malaise. Tolerance may develop to the effects of buprenorphine which means that your benefits from buprenorphine may decrease over time, but this is rarely a problem. Tolerance to buprenorphine usually occurs slowly, if at all. Not all patients respond to buprenorphine. Some patients may only be partially responsive to buprenorphine therapy. Escalating dosages of buprenorphine may indicate that buprenorphine is not effective and therefore might require discontinuation of buprenorphine treatment.

Buprenorphine may compromise your judgement or cause drowsiness that can be worsened if taken with alcohol,benzodiazepines, or other medications such as those prescribed for anxiety, depression, muscle spasm or sleep. Over-the-counter medications, especially antihistamines, can also interact with opioids and cause excessive drowsiness and/or altered judgement. Use caution when driving or operating machinery when taking buprenorphine. The safety of taking buprenorphine with other medications prescribed for muscle spasm, anxiety, depression and/or sleep has not been well established in regard to driving and operating machinery. As such, it is recommended that whenever a patient starts a new medication or changes the dosage of an existing medication, the patient assess the medication’s effect on their alertness, judgement, reaction time, tendency to suddenly doze off, and other symptoms that might compromise the patient’s ability to drive and/or operate machinery prior to doing so. Such focused assessment should be maintained for at least a week subsequent to any change in medication or dosing. This is particularly true for buprenorphine because the full effect of a change in dosing with buprenorphine may take as long as a week to fully appear. Notify the physician immediately if you find yourself compromised by sedation or any other side effects from your buprenorphine or other medications. Due to the inherent danger of drug interactions between buprenorphine and medications belonging to the benzodiazepine class (Valium, Xanax, Ativan etc.), the use of benzodiazepine medications are strongly discouraged and may be grounds for discontinuation of buprenorphine treatment.

A buprenorphine overdose can cause severe side effects, even death, and is more likely to occur when buprenorphine is taken with other opioids, alcohol and/or other sedating medications, especially those prescribed for sleep, muscle spasm, anxiety and/or depression. Abstinence from alcohol is advised when taking buprenorphine.

Common, although usually temporary, side effects of buprenorphine include nausea, itching, and sweating. Constipation also commonly occurs and often does not improve with time – notify your physician if you develop constipation as it may be advised to switch you to discontinue buprenorphine. Use of buprenorphine may lower testosterone levels in both men and women which may result in diminished sex drive or enjoyment of sexual activity, fatigue, depression as well as possibly contributing to reduced bone density (osteopenia or osteoporosis). Bone density testing may be advised. Sleep apnea, if present, may be worsened by buprenorphine. Any patient with a history of sleep apnea, COPD or emphysema must be cautious with use of buprenorphine or other sedating medications. Sleep testing may be advised. Patients must inform the physician if they have sleep disorders, respiratory conditions or any neurologic condition that could place them at risk if they were to be prescribed buprenorphine or other sedating medications.

If female of childbearing capacity:
If you become pregnant while taking buprenorphine, your child may be at increased risk of birth defects. In addition, there is increased risk of complications for the newborn at time of delivery related to buprenorphine use during pregnancy. If you become pregnant, or plan to become pregnant, you must notify the physician immediately. Female patients agree to use reliable methods to prevent pregnancy while being with treated with buprenorphine.

It is impossible to predict specific buprenorphine side effects in any individual patient. Having side effects with one opioid does not necessarily predict side effects with another opioid.

You must take buprenorphine only as directed. Federal law prohibits giving this medication to anyone else.

Discontinuation of buprenorphine management may be required under the following circumstances:
1. Failure to obtain adequate symptom relief.
2. Persistence of side effects.
3. Failure to achieve the goals of buprenorphine treatment.
4. Problematic dose escalation.
5. Failure to comply with treatment agreements.
6. Failure to safeguard your buprenorphine from access by others.
7. Concerns regarding the possibility of diversion (selling, or giving, your buprenorphine to others.
8. Failure to keep scheduled appointments.

I understand and agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding buprenorphine treatment have been adequately answered. If I have further concerns or questions, I will contact the clinic. A copy of this document has been given to me. I give permission to Affordable & Restorative Health to contact my other healthcare providers for the purpose of sharing information concerning my buprenorphine management as the physician deems necessary for coordinated, high quality care. If I do not follow these guidelines, or those described in the “Controlled Substance Agreement”, my buprenorphine management physician may taper me off buprenorphine or abruptly discontinue prescribing buprenorphine.

I acknowledge understanding of this consent and all of my questions have been adequately answered.
Patient 's signature:

Clear
Date:

MonthDayYear
Date
Patient 's name printed:

	Check	Family (F)
History of IV Drug use
Asthma/Respiratory
Hypertension
Head trauma
Liver Problems hepatitis C/B
STD
Cardiovascular (heart attack, high
cholesterol, angina)
Epilepsy or seizure disorder
HIV/AIDS
Pancreatic
Abnormal Pap smear
GI disease
Diabetes
Thyroid disease
Nutritional deficiency

	No	Yes/Past, Yes /Now	Route	How much	How often	Date/time of last use	Quantity last used
Alcohol
Caffeine (pills or beverages)
Cocaine
Crystal Meth-Amphetamine
Heroin
Inhalants
LSD or Hallucinogens
Marijuana
Methadone
Pain killers
PCP
Stimulants(pills)
Tranquilizers /Sleeping pills
Ecstasy
Other:
Other:
Other:

	No	Yes	Age
1. German measles (Rubella)
2. Red Measles
3. Chicken pox
4. Whooping Cough
5. Mumps
6. Rheumatic fever
7. Pneumonia
8. Typhoid fever
9. Malaria
10. Tuberculosis
11. Asthma
12. Hay fever
13. Jaundice(hepatitis)
14. Mononucleosis
15. Meningitis
16. Syphilis
17. Gonorrhea

	Yes	No	Year
Tetanus (lockjaw)
German measles
Pneumovax (pneumonia)
Mumps
TB Skin Test

	Yes	No
Have a pains that made you lie down?
Get tense or jumpy?
Have bleeding or discharge between periods?
Have irregular periods?
Swell before your periods?
If you had menopause (the change)?
Have you had any vaginal bleeding
Hot flashes?
Have you ever had an abnormal pap smear?
So you have a vaginal discharge now?

New Patient OBOT 2023

DSM-IV CRITERIA FOR OPIOID DEPENDENCE DIAGNOSIS: WORKSHEET

APPROPRIATE USE CHECKLIST

APPROPROATE USE CHECKLIST

INDUCTION CHECKLIST

PROBLEM LIST – CURRENT MEDICTIONS

PRESCRIPTION LOG

Medication Dosing Record

Affordable & Restorative Health Care

Explanation of First Visit

Frequent Asked Questions

Patient Treatment Agreement

Clinical Opiate Withdrawal Scale

Quality Care Patient Intake

Medical Profile:

CAGE:

Tobacco History

Medications:

Review of Systems

Activities of Daily Living

Patient Information

Emergency Contact Information

Employment Information

Provider Information

Insurance Information

Secondary Insurance Information

Affordable & Restorative Health Care

Am I Suffering from a Major Depressive Episode?

AUTHORIZATION FOR RELEASE OF INFORMATION

Beck Anxiety Inventory (BAI)

BUPRENORPHINE CONSENT TO TREATMENT FORM

BUPRENORPHINE INFORMED CONSENT

Buprenorphine Taper Interview

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Tuberculosis
Diabetes (sugar in urine)
Cancer
High blood pressure
Heart disease
Mental or emotional disorder
Thyroid disease of goiter
Bleeding tendency or anemia
Alcoholism
Kidney disease
Other family disease

	With Help	Independent
1. Feeding (if food need to be cut up –with help)
2. Moving form care to bed and return (includes sitting up in bed)
3. Personal toilet (wash face, comb hair ,shave ,clean teeth)
4. Getting on and off toilet(handling clothes, wipe, flush)
5. Bathing
6. Walking on level surface(or if unable to walk, propel wheelchair)
7. Ascend and descend stairs
8. Dressing (includes trying on shoes, fastening fasteners)
9. Controlling bowels
10. Controlling bladder

	Yes	No
1. During the same two-week period, I have experienced a depressed mood every day, or nearly every day.
2. During the same two-week period, I have experienced a definite or markedly diminished interest or pleasure in all, or almost all, activities most of the day every day, or nearly every day,
3.During a period of a month, I have experienced significant weight loss when not dieting or weight gain (a change of more than 5% of body weight), or decrease or increase in appetite every day, or nearly every day
4. During the same two-week period, I have experienced insomnia or sleeping more than 10 hours a day every day, or nearly every day.
5. During the same two-week period, I have experienced feeling restless or being slowed down, which others have observed.
6. During the same two weak period, I have experienced fatigue or loss of energy every day, or nearly every day,
7. During the same two-week period, I have experienced feelings of worthlessness or excessive or inappropriate guilt every day, or nearly every day.
8. During the same two-week period, I have experienced diminished ability to think or concentrate, or indecisiveness every day, or nearly every day,
9. During the same two-week period, I have experienced recurrent thoughts of death (not simply a fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.
10. My depressive symptoms have been causing significant distress or impairment in social, occupational, or other important areas of functioning

	Age	Cause of Death	Age at Death
Father
Mother
Brother(s)
Sister(s)