Suboxone Program FORMS PACKET SICK

Transcription

1 , Northampton, Massachusetts Suboxone Program FORMS PACKET SICK

2 Please fill this out and drop it off at 6 Hatfield Street in Northampton. It will be reviewed by our Suboxone Program Coordinator who will call you to discuss scheduling an intake appointment. Before your intake appointment you must read the ORIENTATION MANUAL! The Basics Name: Date of Birth: Health Insurance Company: Policy Number:

3 Social Security Number: Current Address: Home Phone Number: May we leave a message? Yes No Cell Phone Number: May we leave a message? Yes No Health Provider Information Name Address Phone Primary Care Doctor: Psychiatrist: Therapist (MANDATORY): Other: Personal Information Emergency Contact Name: Emergency Contact Phone Number: Are they aware of your addiction? Yes No Do you have any children of your own and/or living in your home? Yes No

4 If so, what are their ages? How did you hear about our program? Employer s Name: Weekly Work Schedule: How long employed? Highest level of Education?

5 Medication Use/Abuse History Drug/Substance Examples/Street Names Usage Barbiturates Benzodiazepines Flunitrazepam Methaqualone Ketamine PCP type drugs LSD Amytal, Nembutal, Seconal, Phenobarbital: barbs, reds, red birds, phennies, tooies, yellows, yellow jackets Ativan, Halcion, Librium, Valium, Xanax: benzos, candy, downers, sleeping pills, tranks Rohypnol: date rape drug, forget me pill, Mexican Valium, R2, roofies, roofinol, rope Quaalude, Sopor, Parest: ludes, mandrex, quad, quay Ketalar SV: cat Valiums, K, Special K, vitamin K Phencyclidine: angel dust, boat, hog, love boat, peace pill acid, blotter, boomers, cubes, microdot, yellow sunshines

6 Mescaline buttons, cactus, mesc, peyote Psilocybin Codeine Fentanyl Heroin magic mushroom, purple passion, shrooms Fiorinal with Codeine, Robitussin AC, Tylenol with Codeine: captain cody, schoolboy Actiq, Duragesic, Sublimaze: Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse Morphine Opium Roxanol, Duramorph: M, Miss Emma, monkey, white stuff laudanum, paregoric, big O, black stuff, block, gum, hop Oxycodone Oxycontin, Percocet:

7 oxy, O.C., killer, percs Amphetamine Cocaine MDMA Methamphetamine Methylphenidate Dexedrine, Adderall: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot ecstasy, Adam, clarity, Eve, lover's speed, peace, STP, X, XTC meth, chalk, crank, crystal, fire, glass, go fast, ice, speed Ritalin: JIF, MPH, R ball, Skippy, the smart drug, vitamin R Marijuana weed, dope, grass, mary jane, pot Nicotine cigarettes, cigars, smokeless tobacco, snuff, spit tobacco, bidis, chew

8 Steroids Dextromethorpha m Inhalants Anadrol, Oxandrin, Durabolin, Depo Testosterone, Equipoise: roids, juice Found in some cough and cold medications; Robotripping, Robo, Triple C Solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide): Typical Use/What you are Currently Using Substance Daily Usage Weekly Usage Example: Heroin 2 bags bags How much money do you spend per week on your habit?

9 At what age did you begin using? What did you start using? When did you start to use opiates? Have you ever shared needles? Yes No Have you ever overdosed? Yes No If yes, how many times? Treatment History Date Treatment Program For treatment of? Clean for? July 1981 Detox One Week Percocet/oxys 3 days clean Do you attend AA or NA meetings?

10 apple Yes If Yes, how many meetings a week? Do you have a sponser? apple No Have you ever been on Methadone Maintenance? apple Yes, I am currently on Methadone Maintenance apple Yes, I have been in the past (If yes, dates: ) apple No, I have never been part of a Methadone program If you are CURRENTLY on Methadone Maintenance: o Program Location: o Counselor s Name: o Current Dosage: o

11 Have you ever been prescribed Suboxone before? apple Yes, I am currently on another Suboxone program apple Yes, I was prescribed Suboxone in the past (If yes, dates: ) apple No, but I buy or have bought Suboxone on the street apple No, I have never tried Suboxone before If you are CURRENTLY prescribed Suboxone: o Physician/Program Name : o Dates: o Current Suboxone Dose: o Why are you leaving? Please help us understand your legal situation Have you ever been arrested because of drug use? apple Yes If yes, please explain: apple No What is the offense or offenses?

12 Have you ever been incarcerated? apple Yes If yes, how long incarcerated? appleapple apple Are you on probation? apple Yes If yes, when is it over? apple No Are you on parole? apple Yes If yes, when is it over? apple No Are you facing potential jail time? apple Yes If yes, how much? apple No Are you currently involved with DSS/DCF? appleapple Yes appleapple No If no, have you ever been?

13 Please help us understand your social support network What is your relationship status? apple Single apple Married apple Long Term Relationship apple Divorced apple Other Do you live alone? apple Yes, I live alone apple No, I live with Do you have children? How Many? If you live with other people, are they aware of your substance abuse issues? apple Yes apple No If you live with other people, do they also use? apple Yes apple No

14 Does anyone in your family have a history of substance abuse? apple Yes apple No Have you been a victim of abuse? Yes No Please help us understand your transportation How will you get to our program? apple I have a car apple I take public transportation apple I live close enough to walk apple I will get a ride from a friend or family member apple Other Our program requires random drug testing. In a random drug test, you will be called and asked to report to the clinic within 24 hours. Will you be able to do this? apple Yes apple No

15 Please help us understand your housing situation Where do you live? apple I have a permanent home apple I am staying with family/friends apple I am living in my car apple I am living on the street apple I am living in a shelter apple I am in an alcohol/drug treatment program apple I consider myself to homeless Please help us understand more about your medical history Medication Allergies: Current Prescription Medications:

16 Surgical History: Past Medical History (such as diabetes, high blood Treatment History for any listed diagnosis? pressure, anxiety, depression, bipolar, schizophrenia, HIV/AIDS, Hepatitis, PTSD, ADD, panic attacks, OCD): Family Medical History (such as diabetes, high blood pressure, anxiety, depression, heart disease) FOR FEMALES ONLY: Yes No Are you currently pregnant? If not, do you use birth control? Yes No What are your goals if you are accepted into the Suboxone program? Is there anything else that you would like us to know about you?

17 Patient Signature: Date: **Before your intake can be scheduled, you must have active insurance, a therapist who you see at least once a week, and referrals from your primary care doctor if required by your insurance. If you are unsure of whether you need referrals, do not hesitate to ask someone at the front desk and they will be able to help you. PATIENT CONTRACT BETWEEN ONCALL URGENT CARE CENTERS AND PATIENTS WHO ARE PRESCRIBED SUBOXONE I will notify the OnCall Urgent Care of any change in my address or phone number. I understand that if I do not do so, I may be liable to receive strikes. I agree to keep, and be on time to, all of my appointments with the physician and/or physician assistant along with the appointments I have scheduled with my substance abuse counselor. I agree not to tamper with ANY urine screens and if I do so, I understand this will be grounds for immediate for discharge from the Suboxone program with referral to a more extensive treatment program. I agree that I will not arrive at the office intoxicated or under the influence of drugs.

18 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 that if my urine test for Suboxone is negative that I will be discharged from the Suboxone program and referred to a more extensive treatment program. I agree that if I have three dilute urine tests that I will be subject to discharge from the program. I agree to be courteous at all times while I am in the Urgent Care Centers and when speaking with staff on the phone. I understand that those that accompany me to the center must also act in this fashion. I agree to inform the Urgent Care Center of any new medications or medical conditions, and of any adverse effects I experience from the medications that I take. I agree to random pill counts I agree to bring my Suboxone bottle to each visit, in the appropriate labeled container. I will not allow anyone else to have, use, sell, or otherwise access my Suboxone. I agree to cooperate with unannounced urine or serum toxicology screens as may be requested. I understand that once I am called that I will have 24 hours to come to the clinic for my drug screen. I agree that medication alone is not sufficient treatment for my disease, and I agree to participate in counseling.

19 I understand that my medical records, course of treatment, and medical care will be kept at OnCall Urgent Care Centers in a medical records system that is a confidential and locked. The notes will be available to any healthcare professional involved in my care. For providers located outside of OnCall Urgent Care Centers, I will be asked to sign consents so that my other health care providers can have access to, and be involved in, my care. I agree to receive my Suboxone from this program only. I understand that the number of appointments that I will be required to keep includes (but is not necessarily limited to): apple Intake Appointment Blood work, physical exam, urine drug test, meeting with director of the program. apple Induction Appointment Evaluation of withdrawal, receipt of prescription apple Medication and Symptom Evaluation one to two days after Induction apple Appointments weekly thereafter until I have been clean for TWELEVE weeks in a row, after which I can move my appointments to every two weeks. apple Bi weekly appointments until I have had FOUR clean urines in a row, after which I can move up to every three weeks. apple Appointments every three weeks until I have had FOUR clean urines, after which I can move up to monthly visits. apple Monthly visits with decreasing Suboxone dosages until I feel like I am ready to stop using Suboxone and have the ability to maintain sobriety on my own.

20 I understand that the OnCall Urgent Care Center Suboxone Program will not release the results of my urine toxicology screen to any other agency, program, or institution without a signed release. The purpose of these tests are for my treatment at only. I understand the potential risks and l benefits of Suboxone and I am entering the Suboxone Program at voluntarily. I understand that I can be discharged from the program at any time. Before signing, please be aware that: apple Patients have died from taking Suboxone apple Patients have died because they mixed their Suboxone with other drugs like methadone and valium apple The long term use of Suboxone and Subutex is controversial apple Suboxone can become addictive apple Some patients may suffer side effects such as constipation and dry mouth. apple Suboxone can cause liver damage and therefore regular blood tests are required I have read the Orientation Manual. Patient Signature: Patient Name: Date: Provider Signature: Provider Name:

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22 Confidentiality of Alcohol and Drug Dependence Patient Records The confidentiality of alcohol and drug dependence patient records maintained by this practice/program is protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless: 1. The patient consents in writing; 2. The disclosure is allowed by a court order, or 3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation. Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime.

23 APPOINTED PHARMACY CONSENT SUBOXONE (buprenorphine HCl/naloxone HCl dihydrate) sublingual tablet SUBUTEX (buprenorphine HCl) sublingual tablet I (patient name), do hereby authorize any employee of the located at 51 Locust Street, Northampton, Massachusetts 01060, to disclose my treatment for opioid dependence to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my buprenorphine prescriptions directly to the pharmacy. I also agree to allow the pharmacist to contact y physician to discuss my treatment if necessary. I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified above is otherwise notified by me. I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient. I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights. Pharmacy Name & Phone Number: Walgreens Pharmacies, Pharmacy Address: 70 Main St. Florence MA 01062

24 Patient Signature: Patient Name: Provider Signature: Provider

25 THERAPIST CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION SUBOXONE (buprenorphine HCl/naloxone HCl dihydrate) sublingual tablet SUBUTEX (buprenorphine HCl) sublingual tablet I (patient name), do hereby authorize any of the employees of the OnCall Urgent Care Center located at 51 Locust Street, Northampton, Massachusetts to disclose or receive information pertaining to my treatment for opioid dependence to or from my Therapist or Substance Abuse counselor: (counselor name). I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified above is otherwise notified by me. I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient. I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights. Patient Signature: Patient Name: Date:

26 Planned Form of Therapy I understand that I am required to participate in substance abuse counseling as part of my participation in Suboxone Program at. To meet this requirement I will be doing the following (please check all that apply): apple Weekly Counseling with (mandatory) apple Weekly attendance at group therapy with (optional) apple Weekly (or more frequently) AA/NA Meetings (optional) apple Other apple Patient Signature: apple Date: CONSENT FOR TREATMENT WITH BUPRENORPHINE AT ONCALL URGENT CARE CENTERS Buprenorphine is a FDA approved medication for treatment of people with opiate dependence. Qualified physicians can treat up to 30 patients for opioid dependence with Buprenorphine for the first year of practice and then can apply for another waiver to increase to 100 patients. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary, it is estimated that one will be on Buprenorphine for at least 6 months. Buprenorphine treatment can result in physical dependence of an opioid. Buprenorphine is generally less intense than with heroin or methadone. Withdrawal from If Buprenorphine is suddenly discontinued, some patients have no withdrawal symptoms; others may have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opioid withdrawal, Buprenorphine should be discontinued gradually over several weeks or more.

27 If you are not in withdrawal, Buprenorphine may cause severe opioid withdrawal. If this is a concern of yours please address the issue during your intake appointment with our Suboxone director. It may take several days to get used to the transition from the opioid that had been taken and using Buprenorphine. During this time any use of other opioids may cause an increase in symptoms. After becoming stabilized on Buprenorphine, the use of other opioid will have less effect. Attempts to override the Buprenorphine by taking more opioids could result in an opioid overdose. You should not take any other medications without first discussing with your health care provider. Combining Buprenorphine with alcohol or other medications may be hazardous. Combining Buprenorphine with medications such as Klonopin, Valium, Haldol, Librium, Ativan has resulted in deaths. The form of Buprenorphine that you will be taking (Suboxone) is a combination of Buprenorphine with a short acting opioid blocker (Naloxone). If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid (i.e. Morphine), it would cause severe opioid withdrawal. Buprenorphine tablets must be held under the tongue until they completely dissolve, Buprenorphine will not be absorbed from the stomach if it is swallowed. Patient Signature: Patient Name: Date:

28 Provider Signature: Provider Name: PRIMARY CARE DOCTOR CONSENT TO RELEASE/RECEIVE CONFIDENTIAL INFORMATION I,, authorize any employee of the OnCall Urgent Care Center Patient Name (Print) at the above address to release or receive my treatment records to or from the following Primary Care Doctor: Primary Care Doctor s Name: Address: Phone Number: This information is for participation in the Suboxone Program.

29 I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the provider specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the provider specified above is otherwise notified by me. I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illnesses. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient. I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.

30 Patient Signature: Patient Name: Date: Witness Signature: Witness Name: PATIENT CONTRACT BETWEEN ONCALL URGENT CARE CENTERS AND PATIENTS WHO ARE Before signing, please be aware that: PRESCRIBED SUBOXONE apple Patients have died from taking Suboxone apple Patients have died because they mixed their Suboxone with other drugs like methadone and valium apple The long term use of Suboxone and Subutex is controversial apple Suboxone can become addictive apple Some patients will suffer side effects such as constipation and dry mouth apple Suboxone can cause liver damage and therefore regular blood tests are required I agree to keep, and be on time to, all of my appointments with the physician and his or her assistant I agree not to tamper with urine screens and if I do so, this may be immediate grounds for discharge from the Suboxone program.

31 I agree that I will not arrive at the office intoxicated or under the influence of drugs. 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 that if my urine test for Suboxone is negative that I will be discharged from the Suboxone program. I agree that a dilute urine test is considered dirty. I agree to receive my Suboxone from this program only. I agree to be courteous at all times while I am in the Urgent Care Centers and when speaking with staff on the phone. I understand that those who accompany me to the center must also act in this fashion. I agree to inform the Urgent Care Center of any new medications or medical conditions, along with any adverse effects I experience from the medications that I take. I agree to bring my Suboxone bottle to each visit, in the appropriate labeled container. I will not allow anyone else to have, use, sell, or otherwise access my Suboxone. I agree to cooperate with unannounced urine or serum toxicology screens and pill counts as may be requested. I understand that once I am called I will have 24 hours to come to the clinic for my drug screen.

32 I agree that medication alone is not sufficient treatment for my disease, and I agree to participate in counseling. I understand that missed therapy appointments will result is suspension. I understand that my medical records, course of treatment, and medical care will be kept at OnCall Urgent Care Centers in a medical records system that is a confidential, locked, filing system. The notes will be available to any healthcare professional involved in my care. For providers located outside of, I will be asked to sign consents so that my other health care providers can have access to, and be involved in, my care I understand that the number of appointments that I will be required to keep includes (but is not necessarily limited to): Intake Appointment Physical Exam Induction Appointments on Days 1 2 Medication and Symptom Evaluation on Day 7 and weekly thereafter until I have 8 tox screens that are clean in a row, after that I can move my appointments to every 2 weeks Moving beyond evaluations at every two weeks will be determined by the treatment team (therapists and providers). I understand that the OnCall Urgent Care Center Suboxone Program will not release the results of my urine toxicology screen to any other agency, program, or institution without my consent I understand the potential risks and l benefits of Suboxone and I am entering the Suboxone Program at voluntarily.

33 I understand that I can be discharged from the program at any time. I have read the Orientation Manual. Please sign below: Patient Signature Patient name (Printed) Provider Signature Therapy Confirmation form Instructions: Patient fills out section one Agree to participate in Substance abuse counseling while in the Oncall Suboxone program.

34 Patients Substance abuse counselor fills out section two. Completed by Counselor Patient return form for Intake or next appointment. 1. I Agree to participate in Substance abuse counseling while in the Suboxone program. My substance abuse counselor is. Phone number. 2. Is engaged in Substance abuse counseling at and has been attending since $$$$_. I will inform you if he/she drops out of treatment. Counselor signature Date. Contact is Lynn MacDonald or Chartrx@hotmail.com

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