Informed Consent for Treatment with Buprenorphine: Buprenorphine is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance 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 possibility of opiate withdrawal, buprenorphine should be discontinued 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. It you are not in withdrawal, buprenorphine may cause significant opioid withdrawal.

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 the medical staff first. Combining buprenorphine with alcohol or some other medications may also be hazardous.

The combination of buprenorphine with benzodiazipine medication such as Valium, Xanax, Klonopin, Librium, and Ativan has resulted in deaths. The form of buprenorphine (Suboxone) you will be taking is a combination of buprenorphine with a short-acting opiate blocker (Naloxone).

If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal. Buprenorphine tables must be held under the tongue until they dissolve completely.

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. Alternatives to buprenorphine Some hospitals that have specialized drug abuse treatment units can provide detoxification and intensive counseling for drug abuse.

Some outpatient drug abuse treatment services also provide individual and group therapy, which may emphasize treatment that does not include maintenance on buprenorphine or other opiate like medications.

Other forms of opioid maintenance therapy include methadone maintenance. Some opioid treatment programs use naltrexone, a medication that blocks the effects of opioids, but has no opioid effects of its own.



(a) Notice required. At the time of admission to a part 2 program or, in the case that a patient does not have capacity upon admission to understand his or her medical status, as soon thereafter as the patient attains such capacity, each part 2 program shall:

(1) Communicate to the patient that federal law and regulations protect the confidentiality of substance use disorder patient records; and

(2) Give to the patient a summary in writing of the federal law and regulations.

(b) Required elements of written summary. The written summary of the federal law and regulations must include:

(1) A general description of the limited circumstances under which a part 2 program may acknowledge that an individual is present or disclose outside the part 2 program information identifying a patient as having or having had a substance use disorder;

(2) A statement that violation of the federal law and regulations by a part 2 program is a crime and that suspected violations may be reported to appropriate authorities consistent with §2.4, along with contact information;

(3) A statement that information related to a patient’s commission of a crime on the premises of the part 2 program or against personnel of the part 2 program is not protected;

(4) A statement that reports of suspected child abuse and neglect made under state law to appropriate state or local authorities are not protected; and

(5) A citation to the federal law and regulations.

(c) Program options. The part 2 program must devise a notice to comply with the requirement to provide the patient with a summary in writing of the federal law and regulations. In this written summary, the part 2 program also may include information concerning state law and any of the part 2 program’s policies that are not inconsistent with state and federal law on the subject of confidentiality of substance use disorder patient records.”.

Federal and State Regulations require your permission for us to discuss your treatment with any other entity. Your privacy is a priority to us. By agreeing with this statement, we have your permission to discuss and share your treatment with Buprenorphine with your Pharmacy, the Laboratory, and appropriate Counselors*




1- I agree to keep appointments and let appropriate staff know if I will be unable to show up as scheduled.

2- I agree to report my history and my symptoms honestly to IntegraMedical physicians, nurses, and counselors. I also agree to inform IntegraMedical staff of all other physicians and dentists whom I am seeing; of all prescription and non-prescription drugs I am taking; of any alcohol or street drugs I have recently been using; and whether I have become pregnant or have developed hepatitis.

3- I agree to cooperate with witnessed drug testing whenever requested by IntegraMedical staff, to confirm if I have been using any alcohol, prescription drugs, or street drugs.

4- I have been informed that buprenorphine, as found in Suboxone, is a narcotic analgesic, and thus it can produce a ‘high’; I know that taking Suboxone regularly can lead to physical dependence and addiction, and that if I were to abruptly stop taking Suboxone after a period of regular use, I could experience symptoms of opiate withdrawal.

5- I have been informed that Suboxone is to be placed under the tongue for it to dissolve and be absorbed, and that it should never be injected or taken IV. I have been informed that injecting Suboxone after taking Suboxone or any other opiate regularly could lead to sudden and severe opiate withdrawal.

6- I have been informed that Suboxone is a powerful drug and is to be respected, and that supplies of it must be protected from theft or unauthorized use, since persons who want to get high by using it or who want to sell it for profit, may be motivated to steal my prescription of Suboxone.

7- I have a means to store take-home prescription supplies of Suboxone safely, where it cannot be taken accidentally by children or pets, or stolen by unauthorized users. I agree that if my Suboxone pills are swallowed by anyone besides me, I will call 911 or Poison Control at 1-800-222-1222 immediately.

8- I agree that if my IntegraMedical doctor recommends that my home supply of Suboxone should be kept in the care of a responsible member of my family or another third party, I will abide by such recommendations.

9- I will be careful with my prescription of Suboxone, and agree that I have been informed that if I report that my prescription has been lost or stolen, that my doctors will not be requested or expected to provide me with a make-up prescription. This means that if I run out of my medication it could result in my experiencing symptoms of opiate withdrawal.  Also, I agree that if there has been a theft of my medications, I will report this to the police and will bring a copy of the police report to my next IntegraMedical visit.

10-I agree to bring my bottle of Suboxone in with me for every appointment with my IntegraMedical doctor so that remaining supplies can be counted.

11- I agree to take my Suboxone as prescribed, to not skip doses, and that I will not adjust the dose without talking with my IntegraMedical doctor about this so that changes in orders can be properly communicated by IntegraMedical to my pharmacy.

12- I agree that I will not drive a motor vehicle or use power tools or other dangerous machinery during my first days of taking Suboxone, to make sure that I can tolerate taking it without becoming sleepy or clumsy as a side-effect of taking it.

13- I understand Suboxone is just one of several types of treatments for opioid dependency, others including Methadone Treatment, in-patient treatment, and other rehab programs. I have chosen Suboxone as my choice of treatment after careful consideration.

14- I have been informed that it can be dangerous to mix Suboxone with alcohol or another sedative drug such as Valium, Ativan, Xanax, Klonopin or any other benzodiazepine drug–so dangerous that it could result in accidental overdose, over-sedation, coma, or death. I agree to use no alcoholic beverages and to take no sedative drugs at any time while being treated with Suboxone. I have been informed that my IntegraMedical doctor will almost certainly discontinue my buprenorphine treatment with Suboxone if I violate this agreement.

15 – I am not pregnant, and will not attempt to become pregnant. If a female, I will not have unprotected sex while I am taking Suboxone, because of the unknown safety of buprenorphine during pregnancy. I have been informed that my IntegraMedical doctor will almost certainly discontinue my buprenorphine treatment with Suboxone if I become pregnant.

16 – I want to be in recovery from addiction to all drugs, and I have been informed that any active addiction to other drugs besides heroin and other opiates must be treated by counseling and other methods. I have been informed that buprenorphine, as found in Suboxone, is a treatment designed to treat opiate dependence, not addiction to other classes of drugs.
17 – I agree that medication management of addiction with buprenorphine, as found in Suboxone

, is only one part of the treatment of my addiction, and I agree to participate in a regular program of professional counseling by IntegraMedical while being treated with Suboxone.

18 – I agree that professional counseling for addiction has the best results when patients also are open to support from peers who are also pursuing recovery.

19 – I agree to participate in a regular program of peer/self-help while being treated with Suboxone.

20 – I agree that the support of loved ones is an important part of recovery, and I agree to invite significant persons in my life to participate in my treatment at IntegraMedical

21 – We will be sending your prescription to one of these pharmacies and they will deliver the medication to the UPS Store closest to your home for pickup. No one will know the contents of the package or anything about your personal business. For a marginal fee, the medication can be delivered directly to your home with a signature required

22- I understand IntegraMedical is a non-denominational religious organization and as such provides lifesaving medical care no different than any other medical mission.

23 – I agree to grant Sovereign Immunity to IntegraMedical, it’s staff, personnel, and all associated persons. This means that, no matter what the circumstances or outcomes, neither myself nor anyone associated with me, including family members, can ever sue or seek damages from IntegraMedical or its associates.

24 -I release and hold harmless IntegraMedical, it’s staff, personnel, and all associated persons from any and all outcomes that may arise from my addiction, the treatment of my addiction, or any behaviors or actions that I may take.

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