Buprenorphine is an FDA approved medication for the treatment of opioid use disorder. Buprenorphine products can be used for detoxification or for maintenance therapy. Some buprenorphine products are a combination of buprenorphine with a short-acting opioid blocker (Naloxone). Maintenance therapy can continue as long as medically necessary. There are other treatments for opioid use disorder, including methadone, naltrexone, and some treatments without medications that include counseling, groups and meetings.

If you are dependent on opioids - you should be in as much withdrawal as possible when you take the first dose of buprenorphine. If you are not in withdrawal, buprenorphine can cause severe withdrawal symptoms. 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 opioid they had been using to the buprenorphine product. 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 the physician first.

I understand that it is important for me to inform any medical provider who may treat me for any medical problem that I am enrolled in an office based opioid treatment program so that the provider is aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my opioid pharmacotherapy or my chances of successful recovery from addiction.

Combining buprenorphine with alcohol or other sedating medications is dangerous. The combination of buprenorphine with benzodiazepines (such as Valium®, Librium®, Ativan®, Xanax®, Klonopin®, etc.) has resulted in deaths.

Although sublingual buprenorphine has not been shown to be liver-damaging, your doctor will monitor your liver tests while you are taking buprenorphine. (This is a blood test.)

Buprenorphine will maintain physical dependence, and if you discontinue it suddenly, you will likely experience withdrawal. If you are not already dependent, you should be aware that it could eventually cause physical dependence.

Buprenorphine tablets must be held under the tongue until they dissolve completely. It is important not to talk or swallow until the tablet dissolves. This takes up to ten minutes. Buprenorphine is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Buprenorphine will not be absorbed from the stomach if it is swallowed. If you swallow the tablet, you will not have the important benefits of the medication, and it may not relieve your withdrawal symptoms.

The maximum daily dose for most patients does not exceed 16 mg. Beyond that dose, the effects of 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.

If you are transferring to Buprenorphine 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 buprenorphine. Your doctor will examine you for clear signs of withdrawal, at which point you can start your buprenorphine induction.

I agree to accept the following treatment contract for office-based buprenorphine treatment:

1. I will keep my medication in a safe and secure place away from children (e.g., in a lock box).

2. I will take the medication exactly as my doctor prescribes. If I want to change my medication dose, I will speak with the doctor first. Taking more than my doctor prescribes is medication misuse that can be dangerous to my health and safety and may result in a higher risk protocol or even discharge from treatment. I understand that I am being prescribed a controlled substance and that DHEC and DEA regulations prevent more medication from being prescribed until the number of days filled have expired. Overusing medication typically results in a patient having to go without or stretch and may cause symptoms of withdrawal. Taking the medication by snorting or by injection is also medication misuse and may result in a referral to a higher level of care, discharge from treatment or change in medication based on the doctor’s evaluation.

 • Early Refills: If I use my medication faster than prescribed and run out early, I will not receive a refill until my next scheduled appointment. This policy is strictly enforced to ensure patient safety and prevent potential misuse. (We encourage you to contact our office as soon as possible if you anticipate running out early so we can discuss strategies to manage your medication effectively.)

• Late Refills: Prescriptions for controlled substances have specific refill windows. If more than five (5) days have passed since the last refill date for any reason, I will be required to present for a follow-up urinary drug screen before a new prescription can be issued. This policy is in place to confirm appropriate medication use and ensure ongoing safety and well-being.

3. I will be on time to my appointments and be respectful to the office staff and other patients.

4. I will keep my doctor informed of all my medications (including herbs and vitamins) and medical problems.

5. I agree not to obtain or take prescription opioid medications prescribed by any other doctor.

6. If I am going to have a medical procedure that will cause pain, I will let my doctor know in advance so that my pain will be adequately treated.

7. If I miss an appointment or lose my medication, I understand that I will not get more medication until my next office visit. I understand that if I do not give 24-hour notice before my scheduled appointment that I will be unable to attend, I may be charged a $25.00 fee for missing my appointment.

8. If I come to the office intoxicated, I understand that the doctor reserves the right to not see me, and I will not receive more medication until the next office visit.

9. I understand that it is illegal to give away or sell my medication – this is diversion and may be reported to the authorities and may result in discharge from treatment.

10. Violence, threatening language or behavior, or participation in any illegal activity at the office will result in treatment termination from our practice.

11. I understand that random urine drug screening is a treatment requirement. If I do not provide a urine sample, it will count as a positive drug test.

12. I understand that I can be called at random times to bring my medication bottle into the office for a medication count. Missing medication may result in mandatory weekly counts, prescriptions only being released weekly, or discharge from treatment.

13. Prescription Frequency: 

 • Initial Phase: New patients will begin with weekly prescriptions for their medication. This allows for the close monitoring of progress, assessment of how the medication is working, and any necessary dosage adjustments.

• Follow-Up Appointment: A follow-up appointment is required 1-2 weeks after the initial intake appointment. This appointment is essential to ensure the medication is in the patient's system, evaluate its effectiveness, and fine-tune the dosage if needed.

• Transition to Monthly Prescriptions: After the completion of the initial intake appointment and the follow-up appointment, the prescription frequency may then transition to monthly (30-day) prescriptions if compliant to all aspects of treatment. 

• Reversion to Weekly Prescriptions: For my safety, if I test positive for any illicit substance, the prescription and/or appointment frequency will revert to weekly. This measure allows for close monitoring of medication usage and to ensure my well-being. I can go back to visits every two weeks to four weeks when I have two negative drug screens in a row. 

14. I understand that people have died by mixing buprenorphine with other drugs like alcohol and benzodiazepines (drugs like Valium®, Klonopin® and Xanax®).

15. I understand that treatment of opioid use disorder involves more than just taking my medication. I agree to comply with my doctor’s recommendations for additional counseling and/or for help with other problems.

16. I understand that there is no fixed time for being on buprenorphine and that the goal of treatment varies per individual.

17. I understand that I may experience opioid withdrawal symptoms when I come off buprenorphine.

18. If female, I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting buprenorphine treatment and have been offered methods for preventing pregnancy.

19. If female, I have been educated about the effects of poor diet, illicit opioid use, use of dirty needles/sharing injection equipment, physical and mental trauma, and lack of pre-natal medical, substance use and mental health care during pregnancy and how these things can adversely affect my health and my current or future fetus/newborn’s health. I understand that neonatal abstinence syndrome can occur when taking illicit opioids and that neonatal abstinence syndrome (NAS) is less severe, but can still occur, when pregnant women take buprenorphine as prescribed/dispensed in substance use disorder treatment. Cigarette smoking can make the severity of NAS worse and cause pre-term birth and small babies. Alcohol use can cause significant cognitive/brain damage in fetuses and newborns.

20. 30-Day Rolling Treatment Program: I understand that this a rolling 30-day treatment program. This means my participation and compliance are assessed on a continuous basis, looking back over the previous 30 days. Successful completion of each 30-day period is required to continue treatment.

Program Requirements: To remain in compliance with the 30-day rolling treatment program, I must meet all of the following requirements:

• Timely Payments:  All payments for services rendered must be made promptly according to an agreed-upon payment schedule.

• Appointment Adherence:  Attending all scheduled appointments is crucial for ongoing care and assessment. Consistent missed or canceled appointments may impact your participation in the program.

• Monthly Screenings:  Compliance with required monthly screenings (e.g., urine drug screens) is essential for monitoring progress and ensuring safety.

21. Prescription Policy: 

• Compliance Required:  Prescriptions will only be issued if I am in full compliance with all aspects of the 30-day rolling treatment program, including timely payments, consistent appointment attendance, and adherence to monthly screening requirements.

• Non-Compliance:  Failure to meet any of these requirements may result in a delay or denial of my prescription refill until compliance is re-established.

• Self-Pay Clients: For self-pay clients, prescription frequency will coincide with payment schedule. For example, if I make bi-weekly payments, I will receive bi-weekly prescriptions (assuming all other program requirements are met and you are in compliance).  If I make monthly payments, I will receive monthly prescriptions (again, assuming full compliance). Exceptions can be made if auto-pay is enabled. 

22. Medication Policy Regarding Urine Drug Screens: As part of our commitment to patient safety and compliance with clinical best practices, routine urine drug screening is a standard component of care. Please be advised that if a urine drug screen returns positive for illicit substances, all additional medications prescribed by our clinic -with the exception of buprenorphine- may be discontinued. This policy is in place to ensure the safe administration of treatment, reduce the risk of adverse interactions, and maintain adherence to our prescribing guidelines. Continued engagement in the program will require an open and honest dialogue with your treatment provider and may include a reassessment of your treatment plan.

FINANCIAL RESPONSIBILITY:

All professional services rendered are charged to the patient and due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments. I understand that I am responsible for turning over payments and EOBs from my insurance carrier for services rendered by Carolina Wellness & Recovery (CWR) within 7 days of receipt or be subject to finance charges and the cost of the collection process.

ASSIGNMENT OF BENEFITS:

I hereby assign all medical and counseling services to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issues payment check(s) directly to CWR for services rendered to me regardless of my insurance benefits, if any. I understand that I am responsible for any and all amounts not covered by insurance. I furthermore understand that I am waiving any anti-assignment clauses that are written into my health care contract. I have requested that the office of CWR be the agent for filing, processing, and appealing of claims related specifically to treatment rendered by this office. I understand that I have the opportunity to submit my bills directly to my health insurance carrier but have chosen voluntarily to have the claims submitted by and paid directly to the office of CWR with the accompanying explanation of benefits.

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize CWR to (1) release any information necessary to insurance carriers regarding my treatments (2) process insurance claims generated in the course of treatment, and (3) allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing.

I have requested services from CWR on behalf of myself, and understand that by making this request, I become fully financially responsible for any and all charges incurred during the course of the treatment.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

We understand the following sections are lengthy, and completing forms can be time-consuming. However, the details you provide are essential for us to deliver personalized care that meets your specific needs. Please take a few minutes to fully read and complete the following:

I authorize Carolina Wellness & Recovery to:

*IF YOU WOULD LIKE CAROLINA WELLNESS & RECOVERY TO BE ABLE TO DISCUSS/DISCLOSE YOUR TREATMENT INFORMATION, LABWORK, DIAGNOSES, BILLING INFORMATION, ETC. WITH AN INDIVIDUAL OTHER THAN YOURSELF, THEY MUST BE LISTED BELOW:

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 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 dependency. 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 understand those rights.

By signing below, I am acknowledging that:

• I am either the patient or the patient's personal representative;
• I have received a copy of the "Notice of Privacy Practices" for Carolina Wellness & Recovery; and 
• I understand that I may contact the person named in the Notice if I have questions about the content of the Notice.

*Full copy of Notice of Privacy Practices is available at the bottom of this page