Treatment Contract

Core Addiction Treatment Contract

Please complete the buprenorphine treatment contract (includes our drug screening policy).,

Suboxone/Buprenorphine Treatment

I understand that buprenorphine treatment for opioid dependence is most effective when combined with traditional substance abuse treatment, including counseling, or a recovery support group.

I understand I should be in at least moderate withdrawal before taking my first dose of buprenorphine. The number of tablets/strips I receive and the frequency of visits will be individually dependent on my progress.

I understand the use of Suboxone by injection will cause immediate and severe withdrawal symptoms.

I agree to take buprenorphine as prescribed. I will safeguard my medications and will keep them away from children. I will not sell, share, otherwise divert any prescribed medications. Lost or stolen medication will not be replaced under any circumstances, unless a police report indicating theft is provided.

I understand that appointments are paid prior to the date of service. Payments are non-refundable, including in the event of a missed appointment.

While taking buprenorphine, I agree to abstain from alcohol, narcotics, cocaine, and other substances not prescribed by my physician. I understand my physician may request urine toxicology testing at any time. In particular, I’m aware that mixing buprenorphine with alcohol, tranquilizers, or benzodiazepines such as Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam), or Xanax (alprazolam) is very dangerous and has resulted in death.

I agree not to obtain medications from other physicians without notifying all of my doctors. I understand that my doctor may review my history of picking up controlled substances by accessing the Controlled Substance Data Program.

I agree to visit with my primary care physician as recommended by the prescribing physician.

I understand that failure to comply with any of the above may result in immediate termination of treatment without appeal.

I have read, understand, and have had the rules of the A101 Treatment Program explained to me and have been given a copy of the Participant Responsibilities and Program Guidelines. My signature below affirms that I understand the program rules, my responsibilities, have been provided a copy of the program guidelines.

Buprenorphine Informed Consent

Suboxone is a (tablet or strip with Buprenorphine and naloxone) and is an FDA approved medication for the treatment of people on heroin or other Opioid addiction. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. There are other treatments for opiate addiction, including methadone, naltrexone, and some treatments without medications that include counseling, groups and meetings.

If you are dependent on opiates-any opiates-you should be in as much withdrawal as possible when you take the first dose of Buprenorphine. IF you are not in withdrawal, Buprenorphine can cause severe opiate withdrawal. We recommend that you arrange not to drive after your first dose, because some patient’s get drowsy until the correct dose is determined for them. Some patient’s find that it takes several days to get used to the transition from the opiate they had been using prior to Buprenorphine. During this time any use of opiates can or could 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 with taking more opiates can or could result in an opiate overdose. You should not take any other medication without discussing it with the physician first and foremost.

Combining Buprenorphine with alcohol or other sedating medications is dangerous. The combination of Buprenorphine with benzodiazepines; such as: (Valium, Librium, Ativan, Xanax, Klonopin. ECT) has resulted in DEATHS. The form of Buprenorphine (Suboxone) you will be taking is a combination of Buprenorphine with a short acting opiate blocker (Naloxone). It will maintain physical dependence, and if you discontinue it suddenly, you will likely experience withdrawal. If you are not already dependent, you should not take Buprenorphine as it could eventually cause physical dependence.

Buprenorphine tablets/strips must be held under the tongue until they dissolve completely. It is important not to talk or swallow until all is dissolved. This process can take up to ten minutes. Then the medication 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. If you swallow the tablet/strip, you will not have the important benefits of the medication, and it may not relieve your withdrawal. Most patients end up at a daily dose of 16 mg to 24 mg of Buprenorphine. (This is roughly equivalent to 60 mg of methadone maintenance). Beyond that does, the effects of Buprenorphine plateau, so there may not be any more benefit to increase in dose. It may take several weeks to determine just the right dose for you. The first dose is usually 8mg.

If you are transferring to the Suboxone from methadone maintenance, your dose has to be tapered until you have been below 30mg for at least a week. There must be at least 24 hours (preferably longer) between the time you take your last methadone dose, and the time you are given your first dose of Buprenorphine. Your doctor will examine you for clear signs of withdrawal, and you will not be given Buprenorphine until you are in withdrawal.

I have read and understand these details about Buprenorphine treatment, including risks and benefits. I understand there are alternatives and wish to be treated with Buprenorphine.

A101 Drug Screening Policy

It is the policy of Core Addiction Care to randomly urine drug screen (UDS) and/or swab test our patients. This is done to maintain the integrity of care provided to the patients within Core . This testing provides us assurance that all medications prescribed are being taken properly and are at the correct therapeutic level within the patient’s system. Core Addiction Care providers prescribe DEA controlled substances when appropriate. When the initial evaluation results in a controlled substance being prescribed, either as a verified continuation of a previous provider or at the request of the patient, a Quick Cup UDS and laboratory UDS will be collected. A UDS will be collected every 28 days thereafter. Testing is done at the discretion of the prescribing provider. If at any time you are requested to complete a test please understand this is a requirement and if refused could result in termination of your treatment with Core.



It is the policy of Core Addiction Care for all patients participating in our substance abuse program to attend 4 hours of group a month prior to his/her scheduled appointment with a provider.With your signature to this document you agree to abide by this policy and understand this is a requirement for treatment.It is the policy of A101 for all patients participating in our substance abuse program to attend 4 hours of group a month prior to his/her scheduled appointment with a provider.



With your signature to this document you agree to abide by this policy and understand this is a requirement for treatment.





I have read and understood the rules of the Core Addiction Care Treatment Program. My consent will remain in effect as long as I am a patient or until I notify Core in writing of any changes.

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