Telehealth Buprenorphine Maintenance Consent for Treatment

Your provider at Ophelia Medical Group, P.C. ("Ophelia"), will be prescribing you buprenorphine (Suboxone, Zubsolv, Bunavail or generic formulations) to treat opioid use disorder (OUD). The goal of this treatment is to reduce or prevent symptoms of withdrawal from opioids, improve how you feel, and to decrease cravings that might prompt returning to opioid use. By signing this form you are agreeing that your treatment goal/s include reducing or eliminating opioid use.

Buprenorphine is an FDA approved medication (typically prescribed as the combination product buprenorphine/naloxone except for pregnant women) for treatment of people with OUD by qualified medical providers. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary and is the gold standard treatment. 

Buprenorphine itself is an opioid, but it is not as strong an opiate as heroin or morphine. Buprenorphine treatment will result in physical dependence however 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 insomnia, anxiety, muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opioid withdrawal, buprenorphine should be discontinued gradually, usually over several weeks or months under close supervision with your Ophelia team. 

The form of buprenorphine you might be taking (Suboxone, Zubsolv) is a combination of buprenorphine with a short-acting opioid blocker (naloxone). If the Suboxone tablet were dissolved and injected it may cause withdrawal. 

Buprenorphine tablets or film must be held under the tongue until they dissolve completely. It is suggested to not eat or drink before taking buprenorphine. Buprenorphine is absorbed over 5-20 minutes into the tissue under the tongue. Some people prefer to only use one film or tablet at a time to enhance absorption. Buprenorphine will not be absorbed from the stomach if it is swallowed and there will be no effects from it. Do NOT swallow buprenorphine like a pill. 

Treatment with buprenorphine has certain risks associated with it, including, but not limited to: sleepiness or drowsiness, constipation, sweating, nausea, itching, vomiting, dizziness, allergic reaction, slowing of breathing rate, slowing of reflexes, or reaction time. While taking buprenorphine you will probably develop a tolerance to analgesic effects of other opioid medications resulting in their lower effectiveness in controlling pain. It is also possible that buprenorphine will not provide complete relief of craving and withdrawal. Sometimes this indicates the need for a dose increase. 

If you are physically dependent on opioids, you should be in mild to moderate withdrawal when you take the first dose of buprenorphine. If you are not in withdrawal, buprenorphine can cause (precipitate) severe opioid withdrawal which may require hospitalization. Some patients find that it takes several days before they can tolerate their first dose of buprenorphine without precipitating withdrawal. This may be especially true among users who have been exposed to fentanyl and other synthetic opioids. After you become stabilized on buprenorphine, it is expected that other opioids will have less effect. Attempts to override buprenorphine by taking higher and higher doses of opioids could result in overdose or death. You should not take any other medication without discussing it with your Ophelia team first. Combining buprenorphine with alcohol or some other medications may also be hazardous. The combination of buprenorphine with medication such as benzodiazepines (Valium, Xanax, Ativan) may increase the risk of overdose. 

Alternatives to buprenorphine

Some hospitals that have specialized drug abuse treatment units can provide detoxification and residential treatment for drug abuse and may use naltrexone injections (Vivitrol) to help prevent relapse. Naltrexone is a medication that blocks the effects of opioids and reduces craving but has no opioid effects of its own. Other forms of opioid maintenance therapy include methadone maintenance. You should discuss risks and benefits of all treatment options with your Ophelia provider.

Patient Responsibilities

  • You agree to avoid driving, working with machinery, or engaging in hazardous activities if intoxicated or experiencing sedation from buprenorphine.
  • You agree to store medication properly. Buprenorphine may be harmful or deadly to children, household members, guests, and pets. The pills/films should be stored in a safe place, out of reach of children. If anyone besides you ingests the medication, you must call the poison control center or 911 immediately. You should understand that it is solely your responsibility to protect the supply of medication. You agree to notify the office immediately in case of lost or stolen medication. If a police report is filed, you must bring in a copy for our records. 
  • You agree to take the buprenorphine only as prescribed. The indicated dose should be taken daily, and you must not adjust the dose on your own. If you wish a dose change, you will contact us via phone or text for an appointment to discuss this with your provider. You also agree to update your Ophelia team about all other medications and treatments that you are receiving. 
  • You agree to intermittent drug testing.
  • If your use of opioids and other drugs repeatedly puts you in dangerous situations, risks harm to you or others, or if you are repeatedly struggling to adhere to treatment recommendations, this may be grounds for termination of treatment from Ophelia and referral for more intensive treatment elsewhere will be provided to you. 
  • You agree to remain under the care of a primary care doctor during your treatment with Ophelia. You understand that Ophelia will only provide a specialized care for the treatment of Opioid Use Disorder. 

Appointments

To schedule an appointment, you should contact your clinician directly using the contact information provided during your first visit, or contact Ophelia at (215) 585-2144 or support@ophelia.com. In case of an emergency, call 911, or go to the nearest emergency room. 

Patient Consent

I have read this form or have had it read to me. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. By agreeing to this Consent for Treatment voluntarily, I give my consent for the treatment of opioid use disorder with buprenorphine.