I understand that Suboxone is currently being sold illegally in Tennessee.
I understand that Suboxone which is sold illegally often ends up in the prisons of Tennessee.
I understand that selling Suboxone is a crime.
To receive Suboxone, I understand that I have a responsibility for public safety.
I understand that random film/pill count are used by Jabbok Treatment Center to protect public safety.
I understand that I will not be prescribed Suboxone if:
I understand that Suboxone is a narcotic. All narcotics, including Suboxone, have a set of benefits and set of risks to me. I will work to increase the benefits I receive from Suboxone. I acknowledge that the requirement of Federation of State Medical Boards is that I continue to improve in function in order to continue to receive my Suboxone.
To release to and obtain from:(name/address/phone# of receiving agency)
Date, Event, or Condition when Consent expires:_______________________
THE INFORMATION I AUTHORIZE TO RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT IS NOT LIMITED TO DISEASES SUCH AS SYPHILIS, GONORRHEA, AND THE HUMAN IMMUNODERICENCY VIRUS, ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME(AIDS).
Patient Signature:____________________________________ Date:_________
Buprenorphine is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Qualified physicians can treat up to 100 patients for opiate dependence. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenalnce therapy can continue as long as medically necessary.
Buprenorphine itself is an opioid, but it is not as strong an opioid as heroin or morphine. Buprenorphine treatment can result in physical dependence of the opiate type. Buprenorphine withdrawal is generally less intense than with heroin or methadone. If buprenorphine is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possiblity of opiate withdrawal, buprenorphine should be discontiued gradually, usually over several weeks or more.
If you are dependent on 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 may cause significant opioid withdrawal. For that reason, you should take the first dose in the office and remain in the office for observation. Within a few days, you will have a prescription for buprenorphine that will be filled in a pharmacy.
Some patients find that it takes several days to get used to the transition from the opioid they had been using to buprenorphine. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on buprenorphine, it is expected that other opioids 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 medication without discussing it with me first.
Combining buprenorphine with alcohol or some other medications may also be hazardous. The combination of buprenorphine with medication such as Valium, Librium, Ativan has resulted in deaths.
The form of buprenorphine you may be taking is a combination of buprenorphine witha short-acting opiate blocker (naloxone). If the buprenorphine tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal.
Buprenorphine tablets must be held under the tongue until they dissolve completely. Buprenorphine is then absorbed over the next 30 go 120 minutes from the tissue under the tongue. Buprenorphine will not be absorbed from the stomach if it is swallowed.
PART I - HISTORY OF PRESENT ILLNESS
What are the principal substances that you currently have difficulty with or use?
PART II - SUBSTANCE HISTORY
PRESCRIPTION PAIN KILLERS:
What did you use, how many per day, and how many to get high?
METHADONE MAINTENANCE TREATMENT:
PART III - MEDICAL HISTORY
Traumatic Brain Injury:
PART IV - PSYCHIATRIC HISTORY
PART V - FAMILY HISTORY
PART VI - SOCIAL HISTORY
Hollingshead Job Categories:
Contact with Criminal Justice:
Employment and Support: