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Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 40.)
This publication is provided for historical reference only and the information may be out of date.
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
Show detailsTreatment agreements/contracts are often employed in the treatment of addiction to make explicit the expectations regarding patient cooperation and involvement in the treatment process. On the following page is a sample addiction treatment agreement/contract that may be a useful tool in working with patients in an office‐based setting.
As a participant in the buprenorphine protocol for treatment of opioid abuse and dependence, I freely and voluntarily agree to accept this treatment agreement/contract, as follows:
I agree to keep, and be on time to, all my scheduled appointments with the doctor and his/her assistant.
I agree to conduct myself in a courteous manner in the physician’s office.
I agree not to arrive at the office intoxicated or under the influence of drugs. If I do, the doctor will not see me, and I will not be given any medication until my next scheduled appointment.
I agree not to sell, share, or give any of my medication to another individual. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal.
I agree not to deal, steal, or conduct any other illegal or disruptive activities in the doctor’s office.
I agree that my medication (or prescriptions) can be given to me only at my regular office visits. Any missed office visits will result in my not being able to get medication until the next scheduled visit.
I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of the reasons for such loss.
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 and other drugs of abuse, can be dangerous. I also understand that a number of deaths have been reported among individuals mixing buprenorphine with benzodiazepines.
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 participate in the patient education and relapse prevention programs, as provided, to assist me in my treatment.
Printed Name _______________
Signature _______________
Date _______________
- Appendix H Sample Treatment Agreement/Contract - Clinical Guidelines for the Use...Appendix H Sample Treatment Agreement/Contract - Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction
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