Treatment Agreement

Treatment Agreement for Medication-Assisted Treatment with Buprenorphine (Suboxone) via Telemedicine

I agree to the following:

To keep all my scheduled appointments or change the appointment in advance, except in case of emergency.
I agree not to sell, share or give any of my medication to another person- this is diversion. If I do this, my treatment will be terminated and I will be reported.
I agree that the medication I receive is my responsibility and I agree to keep it safe and secure. I agree that lost/stolen medication will not be replaced regardless of why it was lost/stolen (pets, children, etc). I understand this medication is extremely dangerous for infants and children and I agree to keep it in a secured place, away from their reach or access.
I agree not to obtain buprenorphine (Suboxone), other opiods, or benzodiazepines (for example: lorazepam, diazepam/valium, clonazepam, alprazolam/xanax, etc.) from any other healthcare providers, pharmacies, or other sources without telling my treating physician. I will report any changes in medication or medical history during the time of my visit.
I understand that mixing buprenorphine with other medication. Especially benzodiazepines (as in #4) can be dangerous. I understand that several deaths have occurred among persons mixing buprenorphine (Suboxone) and benzodiazepines. There is also a risk of overdose death from mixing buprenorphine (Suboxone) with large amounts of alcohol or other type of sedatives, such as barbiturates.
I understand that buprenorphine (Suboxone) by itself is not enough treatment for my addiction, and I agree to participate in counseling/support groups as discussed and agreed upon with my healthcare provider.
I agree to provide random urine samples for drug testing and have my healthcare provider test my blood alcohol level whenever I am asked to do so.
I agree that my goal is to stop using addictive drugs, and that I will work to stop using all addictive and illegal drugs during my treatment with buprenorphine (Suboxone).
I agree that violating this agreement may result in my no longer receiving treatment with buprenorphine (Suboxone).
I understand that if I decrease my use of opioids (stop using heroin, pain pills) or substitute buprenorphine for these drugs, I have a higher risk of dying from an overdose if I relapse. I understand if I relapse, I need to use small doses of opioids until I learn what my body can tolerate.
I understand that if I relapse when I have been taking buprenorphine, at first I may not get high from the other opioids because buprenorphine blocks their effect. I understand that if I keep using larger and larger amounts to get high, I could stop breathing and die.
I will take buprenorphine product (Suboxone) only sublingually (under the tongue to be dissolved). I will never inject Suboxone or take it intravenously (IV) because that could lead to sudden and severe withdrawal.
I understand that once a pharmacy successfully dispenses buprenorphine for me, The Family MD generally cannot change the pharmacies, as this will lead to a red-flag in the state’s prescription monitoring program.
I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is to stop using illicit drugs and become successful in all aspects of my life. Generally the patients with the lowest rates of relapse are those that have been on Suboxone at least 6-12 months.
I understand that if I wish to taper off Suboxone sooner than 6-12 months then I will do so under guidance of my physician. If I suddenly stop taking Suboxone myself, I could experience severe opiate withdrawal.
I understand that I may receive emails to the email address that I used to sign up which may contain sensitive information and I will make sure that no unauthorized person will have access to my email account.
I understand that I will always need to treat the staff with respect, without cursing or yelling, and if I violate this, my treatment will be terminated.

Treatment Agreement

Treatment Agreement for Medication-Assisted Treatment with Buprenorphine (Suboxone) via Telemedicine

To keep all my scheduled appointments or change the appointment in advance, except in case of emergency.

I agree not to sell, share or give any of my medication to another person- this is diversion. If I do this, my treatment will be terminated and I will be reported.

I understand that buprenorphine (Suboxone) by itself is not enough treatment for my addiction, and I agree to participate in counseling/support groups as discussed and agreed upon with my healthcare provider.

I agree to provide random urine samples for drug testing and have my healthcare provider test my blood alcohol level whenever I am asked to do so.

I agree that my goal is to stop using addictive drugs, and that I will work to stop using all addictive and illegal drugs during my treatment with buprenorphine (Suboxone).

I agree that violating this agreement may result in my no longer receiving treatment with buprenorphine (Suboxone).

I understand that if I decrease my use of opioids (stop using heroin, pain pills) or substitute buprenorphine for these drugs, I have a higher risk of dying from an overdose if I relapse. I understand if I relapse, I need to use small doses of opioids until I learn what my body can tolerate.

I understand that if I relapse when I have been taking buprenorphine, at first I may not get high from the other opioids because buprenorphine blocks their effect. I understand that if I keep using larger and larger amounts to get high, I could stop breathing and die.

I will take buprenorphine product (Suboxone) only sublingually (under the tongue to be dissolved). I will never inject Suboxone or take it intravenously (IV) because that could lead to sudden and severe withdrawal.

I understand that once a pharmacy successfully dispenses buprenorphine for me, The Family MD generally cannot change the pharmacies, as this will lead to a red-flag in the state’s prescription monitoring program.

I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is to stop using illicit drugs and become successful in all aspects of my life. Generally the patients with the lowest rates of relapse are those that have been on Suboxone at least 6-12 months.

I understand that if I wish to taper off Suboxone sooner than 6-12 months then I will do so under guidance of my physician. If I suddenly stop taking Suboxone myself, I could experience severe opiate withdrawal.

I understand that I may receive emails to the email address that I used to sign up which may contain sensitive information and I will make sure that no unauthorized person will have access to my email account.

I understand that I will always need to treat the staff with respect, without cursing or yelling, and if I violate this, my treatment will be terminated.

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