I agree to accept the following treatment contract for buprenorphine office-based opioid use disorder treatment:
The risks and benefits of buprenorphine treatment have been explained to me.
The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and non-medication treatments) have been explained to me.
I will keep my medication in a safe, secure place away from children (for example, in a lockbox).
I will take the medication exactly as my healthcare provider prescribes.
If I want to change my medication dose, I will speak with my healthcare provider first.
Taking the medication by snorting or by injection is medication misuse and may result in more frequent visits or referral to a higher level of care or change in medication based on my healthcare provider’s evaluation.
I will do my best to be on time to my appointments.
I will keep my healthcare provider informed of all my medications (including herbs and vitamins) and medical problems.
I agree not to obtain or take prescription opioid medications prescribed by any other healthcare provider without consulting my buprenorphine prescriber.
If I am going to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so that my pain will be adequately treated.
If I miss an appointment or lose my medication, I understand that I will not get more medication until my next office visit.
If I come to the office intoxicated, I understand that my healthcare provider may not be able to see me, and I may have to reschedule.
I understand that it’s illegal to give away or sell my medication; this is diversion. If I do this, my treatment may require referral to a higher level of care and/or a change in medication based on my healthcare provider’s evaluation.
I understand that random urine drug testing is a treatment requirement. If I do not provide a sample it may effect treatment options
I understand that I will be called at random times to bring my medication container into the office for a pill or film count. Missing medication doses could result in referral to a higher level of care at this clinic or potentially at another treatment provider based on my individual needs.
I understand that initially I may have weekly office visits until I am stable. I will get a prescription for 7 days of medication at each visit.
I can be seen every 2 weeks in the office if I have two negative drug tests in a row or the provider and patient deems it appropriate. I will then get a prescription for 14 days of medication at each visit.
I may go back to weekly visits if I have a positive drug test to better monitor your wellbeing. I can go back to visits every 2 weeks when I have two negative drug tests in a row again or the provider and patient decide it is appropriate.
I may be seen less than every 2 weeks based on goals made by my healthcare provider and me.
I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines (drugs like Valium, Klonopin, and Xanax) and Gabapentin.
I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is to find personal recovery and make meaningful improvement in most aspects of my life.
I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.as the patient will become dependent on the medication
I have been educated about the other two FDA-approved medications used for opioid dependence treatment, methadone and naltrexone.
I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting buprenorphine treatment and been informed about methods for preventing pregnancy.