Mid CoastHospital’s

AddictionResourceCenter

Consent for Treatment with Buprenorphine

Indication:

Buprenorphine, (Suboxone) is a Food and Drug Administration (FDA) approved medication for treatment of people with opiate dependence. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary.

Description:

Buprenorphine treatment can result in physical dependence of the opiate type. Buprenorphine itself is an opiate, but it is not as strong an opiate as heroin or morphine. The form of buprenorphine (Suboxone) you will be taking is a combination of buprenorphine with a short-acting opiate blocker (Naloxone). Buprenorphine withdrawal is generally less intense than heroin or methadone withdrawal. 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.

How It Is Taken:

If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of buprenorphine. Buprenorphine tablets must be held under the tongue until they dissolve completely. 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. It may be necessary to begin buprenorphine in the inpatient unit. Some patients find that it takes several days to get used to the transition from the opiate they had been using to buprenorphine. During that time, any use of other opiates may cause an increase in symptoms. After you become stabilized on buprenorphine, it is expected that other opiates will have less effect. Attempts to override the buprenorphine by taking more opiates could result in an opiate overdose. You should not take any other medication without discussing it with the doctor first.

Risks:

Combining buprenorphine with alcohol or some other medications may be hazardous. The combination of buprenorphine with medication such as Valium, Xanax, and Ativan has resulted in deaths. If you are not in withdrawal when you take buprenorphine severe opiate withdrawal may result. If the Suboxone tablets were dissolved and injected by someone taking heroin or another strong opiate, it would cause severe opiate withdrawal. You may find that you are unable to afford the cost of the medication. There are alternatives such as methadone which may be less expensive.

Alternatives to buprenorphine

AddictionResourceCenter can provide intensive outpatient drug abuse treatment services including individual and group therapy. You can seek a referral to detoxification, treatment in long-term residential programs called therapeutic communities which provide a medication-free treatment focus. Other forms of opiate maintenance therapy include methadone maintenance. Some opiate treatment programs use Naltrexone, a medication that blocks the effects of opiates, but has no opiate effects of its own.

I have been provided and understand patient information about buprenorphine/Suboxone detoxification and maintenance. I have been provided opportunities to ask questions and discuss the above information with medical staff and my signature below indicates my informed consent to receive this medication.

Mid CoastHospital’s_Addiction ResourceCenter

Therapeutic Agreement for buprenorphine therapy

This agreement is being undertaken between ___, (the patient), and (the doctor), to define the responsibilities of the patient during treatment with buprenorphine.

I agree that this trial of treatment has been explained to me in terms of the purpose, the side-effects of the medication and the risks involved.

I agree to fill all prescriptions at only one pharmacy. This will allow my doctor to coordinate my care with a pharmacist.

I agree not to arrive at the office intoxicated or under the influence of drugs (including alcohol). If I do, I understand that I will not be prescribed any medication until my next scheduled appointment.

I agree not to sell, share or give any of my medication to another person. I understand that such conduct is a serious violation of this agreement and will result in my treatment with buprenorphine being terminated immediately. If this occurs, I can be referred to a methadone clinic for either detoxification or longer-term maintenance.

I agree that my medication or prescriptions can only be given to me at my regular office visits. If I fail to keep my scheduled appointment I will not be able to get medication until the next scheduled visit.

I understand that urine drug screening is a tool to assist my doctor in managing my addictive disorder and agree to provide samples as requested.

I agree to notify my doctor promptly about any lapse before it shows up on urine drug screening.

I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place. It is recommended that I use a locked safe. I understand that lost or damaged medication will not be replaced.

I agree not to obtain medications from any physicians, pharmacies or other sources without informing my treating physician. I understand that mixing buprenorphine with other medications, especially benzodiazepines such as Valium (diazepam), Klonopin (clonazepam), Ativan (lorazapam), or other drugs of abuse can be dangerous.

I understand that a number of deaths have been reported among persons mixing buprenorphine with benzodiazepines. I understand that my physician will query the prescription monitoring database to obtain a history of my prescriptions.

I agree to take my medication as the doctor has instructed and not to alter the way I take my medication without first consulting the doctor.

I understand that medication alone is not sufficient treatment for my disease and I agree to follow the additional treatment recommendations my doctor will make to assist me in my recovery.

Mid CoastHospital’s AddictionResourceCenter

Buprenorphine Maintenance Treatment

Patient Responsibilities

_____You agree to store medication properly. Medication may be harmful to children, household members, guests, and pets. The pills should be storedin a safe place, out of reach of children. If anyone besides the patient ingests the medication, the patient must call the poison control center or 911 immediately.

_____You agree to take the medication only as prescribed. The indicated dose should be taken daily, and the patient must not adjust the dose on his or her own. If the patient wishes a dose change, he or she will call the clinic for an appointment.

_____ You agree to comply with the required pill counts and urine tests. Urine testing is a mandatory part of office maintenance, and the patient must be prepared to give a urine sample for testing at each clinic visit, as well as to show the medication bottle for a pill count as requested.

_____You agree to notify ARC immediately in case of lost or stolen medication. Medicine will not be prescribed earlier than scheduled.

_____You agree to notify the clinic immediately in case of relapse to drug abuse. Relapse to opiate drug abuse can be life threatening, and an appropriate treatment plan has to be developed as soon as possible. The physician should be informed about a relapse before any urine test shows it.

_____You review the description of office maintenance at this site. This description includes the hours, the phone numbers, the procedure for making appointments, the fees, the requirements for participation in office maintenance such as treatment attendance, and ARC’s responsibilities for patient care.

ARC Medication Assisted Treatment Model

Mid CoastHospital’s Addiction Resource Center Medication Assisted Treatment is designed to provide clients the opportunity to stabilize from opiate dependency and further engage in the recovery process. The use of buprenorphine is not intended to be a crisis intervention. Clients will be selected for the intervention based upon standardized criteria as developed by the American Society of Addiction Medicine (ASAM) and published best practice standards. Other criteria will include:

The ability to engage in treatment and evidence a commitment to all Mid Coast and ARC standards, rules and expectations.

Client participation will be open to ARC clients meeting criteria. Clients will complete a full clinical intake and evaluation and are expected to be engaged in treatment. Treatment will include assessment and preparation for medication assisted treatment.

Inductions will take place in a group format, with three to five clients at a time, over two consecutive days, Monday and Tuesday. Clients, with support of ARC staff will complete all peremptory work prior to induction to include lab work and a baseline drug screen. Clients may be accompanied by a family member or significant other who will be providing support throughout the recovery process.

Clients will arrive in mild withdrawal on Monday morning, having abstained from all opiates. Short acting opiates, like heroin and OxyContin may require you to abstain for a minimum 24 hours. If you have been taking Suboxone without a prescription, you will be required to abstain for a minimum of 36 hours, 48 hours for Methadone. If clients are not in mild withdrawal, they WILL NOT BE STARTED ON THE MEDICATION. Mild withdrawal includes symptoms of goose flesh, sweating, increased pulse rate, cramping, and nausea.

Monday Day One of Induction

  • 8:00 to 9:00 Assess withdrawal (nurse complete Cows) Clinical Opiate Withdrawal Scale
  • 8:15 to 10:00 Doctor reviews labs, assessments, vitals/cows, and meets with client to do assessment
  • 9:00 to 10:00 Clients go to pharmacy to pick up initial prescription.
  • 9:15 to 10:00 Assessment Nurse observes initial dose of medication.
  • 10:00 to 12:00 Client meets with nurse and other Suboxone clients in group session.
  • 11:00 to 12:30 Assess/Cows/re-medication/Testing
  • As appropriate, clients go back to Treatment.

Tuesday Day Two of Induction

  • 8:00 to 9:00 Review past 24 hours with MD., Administer COWS, medications count, take medication as appropriate
  • All appropriate clients go to IOP/treatment

Following Weeks After Induction:

Clients from previous week are scheduled for medication management groups for all follow-up appointments. Groups are scheduled during day time hours and last 90 minutes. Clients will be offered a range of times and days of the week for follow-up medication management groups.

Client may be transferred to other prescribing physicians after they have stabilized. Stabilized is identified by consecutive negative drug screens, consistent participation in groups without no-shows and cancellations.

Phase System

The medication assisted treatment program at ARC operates on a phase system. As a condition of participating in medication assisted treatment, clients are required to attend the most appropriate treatment program recommended for them. This is often IOP and will include continuing care groups following intensive treatment. Clients may always move up or down the phase system as needed and determined by the results of client behavior, drug screening, and treatment attendance.

Timeframes on each level are only guidelines. Movement up or down the system is up to your treatment team and is based upon your responses to program expectations.

Phase I: Evaluation/Stabilization

Attend medication management group one time per week, and:

  • Attend all required treatment sessions
  • Participate in recovery oriented activities
  • Provide random urine drug screens

Phase II: Stabilization/Maintenance

Attend medication management group 2x’s per month, and:

  • Attend all required treatment sessions
  • Participate in recovery oriented activities
  • Provide random urine drug screens

Phase III: Maintenance

Attend medication management group 1 time per month, and:

  • Attend all required treatment sessions
  • Participate in recovery oriented activities
  • Provide random urine drug screens

Phase IV: Discontinuation

Clients who are ready will be assisted to taper or discontinue Suboxone. Readiness may be demonstrated by:

  • Completion of key treatment goals
  • A detailed relapse prevention plan
  • Participation in ongoing community recovery-oriented activities
  • Continued random UDS that demonstrate abstinence from all substances

Expectations for Advancement

In the MAT Phase System

  • If you are being prescribed medicine, the purpose of medication is to facilitate treatment. Continued prescribing is based upon your active participation in treatment.
  • Part of Recovery is being fiscally responsible; therefore payments are due at each group, before the start of group.
  • Attend all treatment sessions and participate.
  • Complete assignments and work on treatment goals and objectives.
  • Please remember to call if not able to attend any treatment session or if you will be late.
  • No use of opioids, benzodiazepines, or stimulants, prescribed or otherwise, unless you speak with the doctor beforehand and/or provide a doctor’s note.
  • If you are prescribed an opioid and do not use it, bring the prescription or unused pills for verification and disposal.
  • Recovery means using skills not substances to manage feelings. The goal of treatment is to abstain from all intoxicants including alcohol, illicit drugs or non-prescribed medications and marijuana.
  • Take all medications only as prescribed.
  • For treatment to be successful it is essential that you give an honest reporting of any substance use.
  • Urine Drug Screens confirm abstinence from all non-prescribed substances; be prepared to give a sample if asked.
  • Tampering with a urine sample in any way is grounds for dismissal from the program.
  • Safeguarding your medications is your responsibility therefore there will be

NO EARLY REFILLS FOR ANY REASON.

  • Do not interfere with another’s recovery in any way.
  • No selling or diverting medication.
  • No misuse of medications.
  • Be prepared for pill counts that confirm proper use of medications.
  • Respect privacy and confidentiality of all participants including the fact that they are in treatment.

To ContactAddictionResourceCenter: To reach ARC to discuss side effects, or any issues that are discussed in your patient responsibilities and agreement please call 207-373-6950. After hours, a therapist on-call number will be listed and you may call this number for urgent assistance. If you are experiencing a life-threatening emergency call 911 or go to your nearest emergency room for help.

Medications/Cost and Support: All clients are responsible for the cost of their medications. Payment is due to the pharmacy at the time you pick up your prescription. Based upon income guidelines, some clients may qualify for assistance with the cost of their medication. Your doctor will work this out with you and note on your prescription how much of each prescription you will be responsible for. Payment for your portion of the medication is due to the pharmacy at the time you pick up your medication. This assistance may not be available every appointment, your participation in treatment, and following program guidelines will determine your ability to qualify as much as your current financial situation. It is important to note that treatment and these medications are in place to help you begin to support and care for yourself. As you begin to get better it is expected you will be better able to take care of the cost of your medical and treatment needs

Physician Fees: There are fees charged each time you visit with the doctor. Fees are due at the time services are delivered or your insurance will be billed. Clients are responsible for all co-pays. There is not a sliding scale available for doctor fees. The fees for physician services are as follows:

Initial office visit- $263.20 - $288.20

Follow up and Maintenance visits- $94.00 – $188.00

My initials and signature below show that I have reviewed the following documents with staff, asked questions, and had my questions explained to me in terms I understand.

_____The risks and benefits associated with Medication Assisted Treatment for opioid addiction using Buprenorphine medications.

_____The therapeutic agreement between myself and The Addiction Resource Center at Mid Coast Hospital.

_____The cost and fees associated with Medication Assisted Treatment.

_____My responsibilities as a client of Medication Assisted Treatment

Client Signature:______Date:______

Witness:______Date:______


Outpatient Behavioral Health

Authorization/Insurance Release and Fee Agreement

MAT Treatment

CLIENT NAMEDOB
I authorize Mid Coast Hospital’s Outpatient Behavioral Health to disclose to
on a continuing basis, information from hospital records relating to my identity, diagnosis, prognosis or treatment as a client of the Outpatient Behavioral Health Services Program. I understand that the specific type of information to be disclosed includes:
  • My identity as a patient of Mid Coast Hospital/Outpatient Behavioral Health
/
  • Medical history

  • The reason for my seeking services at this facility
/
  • Assessment information

  • Treatment plans
/
  • Type of service
/
  • Discharge summary and plans

The disclosure of this information is for the purpose of obtaining benefits.

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that I have the right to request to review information prior to release. Federal regulation 42 CFR Part 2 also prohibits the above named Recipient from re-disclosure without my specific written consent, or as otherwise permitted by such regulations. I understand that Mid Coast Hospital’s Outpatient Behavioral Health Services cannot guarantee that the Recipient will not re-disclose this information to a third party. I understand that I can revoke this consent in writing at any time except to the extent that action has already been taken. This authorization will remain in effect until all MCHOPBH billing and/or requests have been completed.

FEES FOR SERVICES FOR MEDICALLY ASSISTED TREATMENT SERVICES:

Induction / First session:$ 263.20 - $288.20*MAT Transfer, Follow up, Maintenance $ 94.00 – $188.00 per session*

Please Note: Urine Drug Screen (UDS) and other lab testing as billed by Mid Coast Hospital Laboratory

The client is responsible for payment according to the schedule below and payment is requested at time of service: