Capeside Addiction Care Policies
I understand that medication alone is not sufficient treatment and I agree to participate in the recommended treatment of counseling which is an important part of this program. I am required to attend group sessions four times a month to meet the requirements of attending four hours of groups within a 28-day period; failure to do so will result in the inability to see the prescribing physician for my prescription. I have been advised that I cannot attend two groups within the same week as it would not be beneficial to my treatment by having a three-week gap in services. All patients in the Suboxone/Buprenorphine treatment program will follow these policies as written. Any deviation of this policy by the patient will place the patient in a non-compliant status. As a patient, if you have two areas of non- compliance within a two month or less period you will be discharged from the treatment program (example: 1 missed group and 1 failed urine test).
I understand that Capeside reserves the right to access the NC controlled substance data reports to ensure my compliance with this treatment program. Capeside will check Suboxone/Buprenorphine treatment program patient reports monthly or when deemed necessary. Patients who are found to be getting prescriptions that are prohibited will be discharged immediately. I understand that all Suboxone/Buprenorphine patients are required to have a urine drug screening monthly. Once a test is requested patients are required to produce the test within two hours. Failure to produce the test within the two hours or refusing to test will be considered a failed urinalysis which may result in discharge from the program.
I understand Capeside reserves the right to complete a urinalysis at a minimum of two weeks prior to my doctor appointment. If the test produces a second positive result in any category other than what I have been prescribed, will be discharged from the Suboxone/Buprenorphine program. A positive drug screening for Benzodiazepines, Amphetamine/Methamphetamine, Opiates, Cocaine, or other illicit drugs will constitute a failed drug screening. I have been advised that I may have a urinalysis during my group sessions and if I do not have a urinalysis completed two weeks prior to my doctor’s appointment, I am required to complete a urine test prior to seeing my prescriber.
I understand that as a patient of the Suboxone/Buprenorphine treatment program I will be required to sign a letter of non-compliance if I produce a positive drug screening. This letter will become a permanent part of my medical record.
I understand that NO MEDICATION is kept on site including Suboxone, Subutex, or any other Narcotic. I agree that group is a requirement of treatment and I must attend at least two groups within a 28-day period to receive my prescription. Any missed group sessions prior to my doctors’ appointment will result in me not being able to get medication until my next scheduled visit and once I meet all the treatment requirements to remain in compliance.
1. I agree that the medication I receive is my responsibility and that I will keep it in a safe and secure location. I agree that lost medication will not be replaced regardless of reason.
2. I agree to take my medication exactly as prescribed by the doctor and not to alter my medication schedule without first consulting the doctor. It is a felony to be found trading or selling your prescription; prescription/ medication counting maybe utilized during my treatment to ensure I am taking the medication exactly as prescribed. I agree not to sell, share, or give away any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in discharge from treatment without recourse for appeal or reimbursement.
3. I agree not to obtain medications from any physicians, pharmacists, or other sources without informing my treatment physician. I understand that mixing Suboxone/Buprenorphine with other medications, especially Benzodiazepines (such as: Valium-(diazepam), Xanax-(alprazolam), Librium- (chlordiazepoxide), Ativan-(lorazepam), KlonoPin, and/or any other drugs of abuse including alcohol can be dangerous. I also understand the number of deaths has been reported in persons mixing Suboxone/Buprenorphine with Benzodiazepines.
I understand that I may be discharged immediately if I test positive for any controlled substances.
Suboxone is a (tablet or strip containing Buprenorphine and Naloxone) and is an FDA approved medication for the treatment of people on heroin or other Opioid addiction. Suboxone/ Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue if 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 Suboxone/Buprenorphine IF you are not in withdrawal, Suboxone/Buprenorphine can cause severe opiate withdrawal. We recommend that you arrange not to drive after your first dose, because some patients’ get drowsy until the correct dose is determined for them. Some patients’ find that it takes several days to get used to the transition from the opiate they had been using prior to Suboxone/Buprenorphine During this time any use of opiates can or could cause an increase in symptoms. After you become stabilized on Suboxone/Buprenorphine, it is expected that other opiates will have less effect. Attempts to override the Suboxone/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 Suboxone/Buprenorphine with alcohol or other sedating medications is dangerous. The combination of Suboxone/Buprenorphine with Benzodiazepines, such as: (Valium, Librium, Ativan, Xanax, KlonoPin. ECT) has resulted in DEATHS. The form of Suboxone/ Buprenorphine (Suboxone) you will be taking is a combination of Suboxone/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 Suboxone/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 medications are 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.
Suboxone/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 dose, the effects of Suboxone/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 must 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 Suboxone/Buprenorphine Your doctor will examine you for clear signs of withdrawal, and you will not be given Suboxone/Buprenorphine until you are in withdrawal.
I have read and understand these details about Suboxone/Buprenorphine treatment, including risks and benefits. I understand there are alternatives and wish to be treated with Suboxone/Buprenorphine.
Suboxone/Buprenorphine Treatment Contract
I hereby agree to the following:
1. I understand that Suboxone/Buprenorphine treatment for Opioid dependence is most effective when combined with traditional substance abuse treatment, including counseling, or a recovery support group.
2. I understand I should be in at least a moderate Opioid withdrawal before taking my first dose of Suboxone/Buprenorphine the number of tablets/strips I receive, and the frequency of visits will be individually dependent on my progress.
3. I understand that the use of Suboxone by injection or by snorting will cause immediate and severe withdrawal symptoms.
4. I agree to take Suboxone/Buprenorphine as prescribed; I will safeguard my medications and will keep them away from children. I will not resell, share or otherwise divert any prescribed medications. “LOST” or “STOLEN'' medications will not be “REPLACED” under any circumstances, unless a police report indicating theft is provided.
5. I understand that all appointments are paid on the “DATE OF SERVICE”. Payments are non-refundable, including the event that I miss an appointment.
6. While taking Suboxone/Buprenorphine I agree to abstain from alcohol, narcotics, cocaine, and other substances not prescribed by my physician.
7. I understand my physician may request a urine toxicology testing at any time.
8. I am aware that mixing Buprenorphine with alcohol, tranquilizers or benzodiazepines is very dangerous and has resulted in death. (I.e., Valium, Xanax, Ativan, KlonoPin).
9. I agree not to obtain medications from other physicians without notifying all my doctors.
10. I understand that my doctor may review my history of picking up controlled substances by accessing the North Carolina Controlled Substance Data Program. agree to visit with my primary care physician as recommended by the prescribing physician.
11. I understand that failure to comply with any of the above may result in immediate treatment termination, without appeal.
Group attendance is a requirement for treatment; group is a safe and trusting place to share difficulties you may be experiencing throughout your recovery.
1. There will be no discussion of things that are discussed in group by other group members outside of group setting. This is a basic violation of group trust, against the law, and will NOT be tolerated. If you are found to be discussing other group member’s discussions or concerns outside of group, you will be discharged from treatment.
2. I further understand that I may have to repeat the patient assessment process and will have to pay additional fees if I am discharged from the program and then readmitted to the program (when space is available).
3. I agree to conduct myself in a courteous manner while in the Capeside Addiction Care Program.
4. I agree to not arrive intoxicated or under the influence of drugs. If I do, the staff will not see me, and I will not be given any medication until my next scheduled appointment.
I acknowledge that any diversion related to my medications (i.e., selling, distributing and/ illegal activities) is a felony and can be/is punishable by law causing jail time.
All individual appointments require a 24-hour cancellation notice: if you do not cancel your appointment within the 24-hour window you will be charged for a No-Show Fee of $25.00. I understand that if I fail to show for the scheduled appointment, I will be required to pay the $25.00 No- Show Fee prior to my doctor visit. I understand that A101 does not accept insurance and/or checks for this treatment program all fees are cash and debit/credit cards only.
1. I have acknowledged the financial policy to include the payment options and it is my responsibility to remain compliant within the program to help with my treatment plan.
2. I further understand if I am discharged from the program for any reason, I am not released from my financial obligations.
3. I fully understand A101 reserves the right to discharge me from the program if I violate any part of this agreement.
I am requesting that A101 provide Medication Assisted Treatment (MAT) with Suboxone/Buprenorphine as part of my opioid addiction. I freely and voluntarily agree to accept this treatment agreement with my signature below affirming I have read and thoroughly understand this agreement and will adhere to all policies and responsibility.