Buprenorphine Interactive Treatment Agreement

Providers: Use this form as a guide to create your Buprenorphine Treatment Agreement. This form is in-development and in the future we hope to have it produce a printable agreement for you and your patient to sign.

Buprenorphine Practice Policies Building Engine For Medical Providers Data Entry Form

Step 1 of 7

Introduction
Policies to guide patients toward behaviors that will improve buprenorphine treatment outcomes, result in better compliance and retention [1]. Treatment structure clarifies expectations of patients, which is often welcomed by the patient, in addition to supporting the operation of your clinic and helping to prevent diversion. Putting these policies in writing for patients is recommended recommended in expert developed guidelines [2,3,4] Instructions: Use this form to generate a list of office policies and a doctor-patient treatment agreement for your buprenorpine practice. The policies cover office, prescription, and treatment procedures and expectations of patients.
View References
1. Öhlin L, Fridell M, Nyhlén A. Buprenorphine maintenance program with contracted work/education and low tolerance for non-prescribed drug use: a cohort study of outcome for women and men after seven years. BMC Psychiatry. 2015; 15:56 (ISSN: 1471-244X). 2015; 15(56): ISSN: 1471-244X. Available at: http://www.medscape.com/medline/abstract/25881164 Accessed on: 2015-09-17.
2. SAMHSA. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series, No. 40. Center for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. Available at: http://www.ncbi.nlm.nih.gov/books/NBK64245/ Accessed on: 2015-09-23.
3. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. Federation of State Medical Boards. http://www.fsmb.org. 2013. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2013_model_policy_t... Accessed on: 2015-09-23.
4. Farmer CM, Lindsay D, Williams J, Ayers A, Schuster J, Cilia A, Flaherty MT, Mandell T, Gordon AJ, Stein BD. Practice Guidelines for Burprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process. Substance Abuse Journal. 2015; 36(2): . Available at: http://www.tandfonline.com/doi/pdf/10.1080/08897077.2015.1012613 Accessed on: 2015-09-25.
Policy Sources
Policies described in this document are derived from several sources:
- The original guide for prescribing buprenorphine, SAMHSA's Treatment Improvement Protocol (TIP) on the use of buprenorphine in the treatment of opioid addiction, TIP Number 40 [1]
- The updated policies on buprenorpine treatment produced by the Federation of State Medical Boards' Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office [2]
- An update and expansion of these guideline developed by an expert panel of expert consultants and intended to provide guidance based on accumulated experience and expert consensus based on 14 years since DATA 2000 was first enacted [3]
- ASAM's National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use [4].
View References
1. FSMB. Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office. Federation of State Medical Boards. http://www.fsmb.org. 2013. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2013_model_policy_t... Accessed on: 2015-09-23.
2. SAMHSA. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series, No. 40. Center for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. Available at: http://www.ncbi.nlm.nih.gov/books/NBK64245/ Accessed on: 2015-09-23.
3. Farmer CM, Lindsay D, Williams J, Ayers A, Schuster J, Cilia A, Flaherty MT, Mandell T, Gordon AJ, Stein BD. Practice Guidelines for Burprenorphine for the Treatment of Opioid Use Disorders: Results of an Expert Panel Process. Substance Abuse Journal. 2015; 36(2): . Available at: http://www.tandfonline.com/doi/pdf/10.1080/08897077.2015.1012613 Accessed on: 2015-09-25.
4. American Society of Addiction Medicine (ASAM). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. June 1, 2015. Available at: http://www.asam.org/docs/default-source/default-document-library/asam-na... Accessed on: 2015-10-06.

Save and Continue Later

	Yes	No
A list of policies, reviewed in person with patients
A paper copy of policies given to patients
A copy of policies emailed to patients
Presenting policies as a written agreement between doctor and patient
A written agreement that must be signed by patients
A written agreement that must be signed by provider

	Yes	No
Long term maintenance on buprenorphine
Maintenance followed by taper
Maintenance followed by taper with antagonist therapy
Detoxification
Detoxification followed by antagonist therapy
On site counseling

Buprenorphine Interactive Treatment Agreement

Buprenorphine Practice Policies Building Engine For Medical Providers Data Entry Form

Step 1 of 7

Introduction

Policy Sources

Introduction

Office Policies

Appointments

Patient/Physician Contacts

Payment of Fees for Buprenorphine Treatment

Introduction

Office Based Opioid Treatments Provided

Prescription Policies

Introduction

Mental Health Screening

Urine Drug Screening Policies

Substance Use Screening Questionnaires

Dose Changes Must Be Approved

Introduction

Mandatory Patient Expectations

Avoiding the Use of Substance(s) with Potential Adverse Interactions or Poorer Outcomes

Taking Medication as Instructed

Safe Storage & Disposal and Non-Sharing of Medications

Pregnancy Policy: Patients of childbearing age must disclose pregnancy or if they are planning to become pregnant.

Introduction

Optional Patient Expectations

Medication Supply Counts

Counseling and Other Treatments

Optional Treatment Policies

Risks/Benefits

Introduction

Criteria for Treatment Success

Relapse and Problematic Behaviors

Patient Conduct

Relapse Policies

Buprenorphine Practice Policies Building Engine For Medical Providers Data Entry Form

Step 1 of 7

Introduction

Policy Sources

Introduction

Office Policies

Appointments

Patient/Physician Contacts

Payment of Fees for Buprenorphine Treatment

Introduction

Office Based Opioid Treatments Provided

Prescription Policies

Introduction

Mental Health Screening

Urine Drug Screening Policies

Substance Use Screening Questionnaires

Dose Changes Must Be Approved

Introduction

Mandatory Patient Expectations

Avoiding the Use of Substance(s) with Potential Adverse Interactions or Poorer Outcomes

Taking Medication as Instructed

Safe Storage & Disposal and Non-Sharing of Medications

Pregnancy Policy: Patients of childbearing age must disclose pregnancy or if they are planning to become pregnant.

Introduction

Optional Patient Expectations

Medication Supply Counts

Counseling and Other Treatments

Optional Treatment Policies

Risks/Benefits

Introduction

Criteria for Treatment Success

Relapse and Problematic Behaviors

Patient Conduct

Relapse Policies

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