Forward
At Community Pillars Health and Recovery Centers, our mission is to walk alongside each client with dignity, compassion, and evidence-based care as they pursue recovery. Our approach is comprehensive, integrating medical, psychological, and social support services to provide the highest quality of care for individuals affected by substance use and co-occurring mental health disorders. This consent form is part of our Medication-Assisted Treatment (MAT) program. MAT combines FDA-approved medications such as Buprenorphine (Suboxone/Subutex) with individual and group therapy, psychiatric services, peer support, and case management. This integrated approach is designed to reduce cravings and withdrawal symptoms, support long-term recovery, and help clients build a meaningful, substance-free life. We believe that recovery is not just about avoiding substances, but about rebuilding relationships, reclaiming self-worth, and restoring hope. Your treatment plan will be personalized to your needs, and our staff is here to support you at every step. Please read the following information carefully and speak to your provider if you have any questions or concerns.
Purpose of Treatment
You are being prescribed Buprenorphine (Suboxone or Subutex) as part of a structured treatment plan for opioid use disorder. This medication reduces withdrawal symptoms and opioid cravings, supporting your recovery process through Medication-Assisted Treatment (MAT). Buprenorphine may be prescribed for detoxification or maintenance treatment based on your individualized care plan.
Medication Information
Administration
Responsibilities of the Patient
By signing this agreement, you agree to the following conditions, which are essential to ensuring your safety and the success of your recovery:
- Take the medication exactly as prescribed. Do not alter the dose or schedule without approval. Failure to comply may result in health risks or discontinuation of treatment
- Attend all scheduled appointments including therapy, group sessions, case management, and medical follow-ups. Missed appointments may disrupt your care and result in temporary suspension of medication refills.
- Submit to random drug screenings and pill counts as required. Refusal or tampering may be considered non-compliance and jeopardize continued treatment.
- Inform your provider of any side effects, relapses, changes in health, or if you become pregnant. Open communication helps protect your safety and allows for appropriate medical response.
- Notify your provider of any upcoming medical procedures. This is necessary to coordinate care and ensure safe medication management.
- Do not share, sell, or misuse your medication. Any evidence of diversion will lead to immediate review and possible termination from the program.
These responsibilities are in place to support your recovery, protect your health, and maintain the integrity of the program.
Risks and Side Effects
You have been informed and understand the following risks, along with potential management strategies:
- Drowsiness, dizziness, headache, nausea, constipation: These are common side effects. Staying hydrated, eating small meals, and resting can help manage these symptoms. Let your provider know if they persist or worsen.
- Respiratory depression when combined with alcohol, benzodiazepines, or other depressants: This is a serious and potentially fatal risk. Never mix Buprenorphine with these substances. Inform your provider immediately if you are prescribed or using any sedatives.
- Physical dependence and withdrawal if stopped abruptly: Buprenorphine is an opioid and should be tapered off under medical supervision. Do not discontinue without discussing with your provider.
- Liver complications: Although rare, liver issues may occur. Regular lab work may be required to monitor liver function. Inform your provider if you experience yellowing of the skin or eyes, dark urine, or persistent fatigue.
- Potential for misuse, diversion, or overdose if misused: Always keep your medication in a secure place. Taking more than prescribed, or combining with other opioids, can result in overdose or death.
- Potential for misuse, diversion, or overdose if misused: Always keep your medication in a secure place. Taking more than prescribed, or combining with other opioids, can result in overdose or death.
Mixing Buprenorphine with other opioids (e.g., heroin, fentanyl, OxyContin), benzodiazepines (e.g., Xanax, Klonopin), or alcohol greatly increases the risk of overdose and death. It is critical to avoid these combinations and follow your treatment plan exactly.
If you experience any side effects, you are encouraged to contact your provider promptly. Many side effects can be managed or minimized with adjustments to your care plan.
Missed Appointments, Medication Loss, and Non-Compliance
Pregnancy, Pain Management, and Medical Disclosure
Telehealth and Remote Appointments
In some cases, your treatment may be provided via telehealth, which includes secure video conferencing and/or telephone appointments. By signing this form:
Technical Requirements:
To participate in telehealth services, you will need:
If you have concerns about your ability to meet these requirements, please inform your provider so we can make appropriate accommodations.
Alternatives to Buprenorphine
You have the right to understand and consider other treatment options besides Buprenorphine. Below is a summary of common alternatives, including their benefits and limitations:
Methadone:
A full opioid agonist used in opioid treatment programs. It is highly effective for preventing withdrawal and reducing cravings. However, it requires daily visits to a certified clinic and carries a higher risk of sedation and overdose if not closely monitored.
Naltrexone (Vivitrol):
A non-opioid medication that blocks the effects of opioids. It is administered as a monthly injection or taken orally. It is not addictive and has no potential for misuse. However, individuals must be fully detoxed from opioids for 7–10 days before starting treatment, which can be a barrier for some.
Inpatient detoxification:
A short-term, supervised medical program to manage acute withdrawal symptoms. This option is helpful for those needing 24-hour care during early recovery but does not offer long-term support unless followed by additional treatment services.
Behavioral-only treatment programs:
These include therapy, peer support, and case management without the use of medications. While effective for some individuals, they may not provide sufficient support for those with severe dependence or a history of relapse.
Each of these treatment options has its own unique approach and may be appropriate depending on your individual needs, health status, and treatment goals. Your provider will help you evaluate these options in the context of your overall recovery plan. These alternatives have been explained to me by my provider, and I have had the opportunity to ask questions and consider them in making an informed decision about my treatment.
Consent and Acknowledgment
I confirm the following:
If you have any questions about this agreement, please ask your treatment team before signing. We are committed to your safety and success at Community Pillars Health and Recovery Centers.
