I hereby apply for treatment with buprenorphine and naloxone (Suboxone® and Subutex®) to reduce or prevent symptoms of withdrawal from opioid drugs and to promote abstinence from those drugs. I certify that I am currently dependent on opiate analgesic drugs (for example, heroin,morphine, hydrocodone, oxycodone) or at risk of relapse.
I understand that if I choose not to undergo treatment with buprenorphine I assume risks of discomfort and illness related to opiate withdrawal and risks associated with continued dependence on opiate drugs. This includes but is not limited to risk of overdose, needle born infection, legal problems, disability, harm to others, and even death.
I understand that risks associated with buprenorphine induction and maintenance include, but may not be limited to:
I agree to keep on my person at all times written identification and information for medical providers indicating that I am taking buprenorphine.
Other drug use
I agree to inform Dr. Edwards of all other drugs I use, by prescription or otherwise. I understand that use of certain other drugs may increase risks associated with use of buprenorphine alone and that these risks include relapse and death.
I give Dr. Edwards consent to test my oral fluid, blood, urine or other sample for other drugs of abuse on a random basis or on demand. I understand that I will be responsible for the fee for this and any other laboratory testing ordered by Dr. Edwards and that this is not included in the fee for any other service. I understand that positive tests for other drugs of abuse may be grounds for termination of treatment and/or referral for more intensive treatment elsewhere.
I certify that the goal of my treatment is abstinence from drugs of abuse with the sole exception of buprenorphine.
General medical care
I certify that I am currently under the care of _________________________________________ (primary care provider). I agree to remain under the care of a primary care provider during my treatment by Dr. Edwards. I understand that Dr. Edwards will not perform complete physical examinations in connection with my buprenorphine treatment.
Lost or stolen prescriptions
I understand that buprenorphine is a controlled substance which may be dangerous if not used under medical supervision. I understand that it is solely my responsibility to protect my supply of medication. I understand that Dr. Edwards will not replace stolen or lost prescriptions. If Dr. Edwards, at his sole discretion, elects to replace my supply of buprenorphine confiscated by law enforcement, I agree to authorize Dr. Edwards to contact the department to advise them not to return the confiscated buprenorphine to me. I understand that I must keep buprenorphine in the current pharmacy container and that when away from home I should have in my possession only enough to last until I return home.
Termination of treatment
I understand that I may stop treatment at any time, but I agree to inform Dr. Edwards of my intent to do so. I understand that my treatment may be terminated by Dr. Edwards at any time for any reason, including failure to keep or pay for an appointment, or for no reason. Although Dr. Edwards may be ethically bound to continue responsibility for my care for 30 days after he has informed me that my treatment is terminated, I understand that this does not necessarily include continued prescription of buprenorphine.
I understand that if Dr. Edwards is unable to continue practicing due to illness, death, or for other reasons, I may need to find another qualified physician with little or no advance notice. I understand that because of the 30 and 100 patient limits on how many patients a physician may treat with buprenorphine at a time I may not be able to find another qualified physician soon enough to avoid withdrawal from the drug.
Consent to release protected health information
I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment of psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for psychiatric disorders/mental health, or drug and/or alcohol use, Dr. Edwards is specifically authorized to release such diagnosis to my pharmacy for the purpose of ordering medication and to a laboratory for the purpose of ordering laboratory analysis.
Different patients describe withdrawal from buprenorphine as mild to severe in discomfort, but it is rarely dangerous. If you discontinue treatment or if Dr. Edwards discharges you, you may choose to go through withdrawal or you may seek medical detoxification. Dr. Edward does not provide this service.