SUBOXONE Practice Management Resources/Forms

In support of your treatment efforts, the SUBOXONE Practice Management Resources were created to help you and your staff prepare for and manage treatment of opioid-dependent patients. Our primary goal is to support you in your efforts to provide Patient-focused Quality Care and to assure appropriate use of SUBOXONE.

How to Use the Practice Management Resources

The resources provided here are organized by practice considerations (preparing to treat with SUBOXONE and working with other professionals) and phases of treatment. To access any of the forms or handouts, simply double-click on the specific handout that you wish to print. This website automatically launches the file in Microsoft^® Word or Adobe^®Reader^®. The program and the website are open simultaneously.

Forms or Handouts in Word. The majority of the forms and handouts are provided as Microsoft^® Word documents, allowing you to customize them to meet the needs of your practice. You may:

• Modify, delete, or add content

When you have finished customizing the Word file, save it to your desktop or a folder just as you would save any Word document. You may also print it out in the same way.

Forms or Handouts in Adobe^® Reader^®. Other forms are available in portable document format (PDF) files that require Adobe^®Reader^® reader for viewing and printing. You may save them to your desktop or a folder and print them as you would a Word file. However, this format does not permit you to customize materials, since some are copyrighted.

After Downloading Materials. To return to the website, close Word or Adobe^®Reader^®. This will take you back to the Practice Management Resources right where you left off.

• Setting Up Your Practice
• Working With Pharmacists
• Working With Counselors
• Patient Screening
• Pre-First Visit & Intake
• Induction
• Maintenance

Setting Up Your Practice

To prepare your practice for opioid dependence treatment, we recommend that you prepare and educate your staff so that they are comfortable with the new services you provide and their accompanying responsibilities. The resources below are meant to assist you with this.

• Notification of Intent [PDF]―You may use these forms to apply for certification to administer and prescribe SUBOXONE medication for 30 or 100 patients, respectively
• Complete Preparation Checklist [PDF]―This document covers every aspect of preparing your office for administering and prescribing SUBOXONE medication, including: legal, staff, and pharmacy preparation; treatment considerations; and marketing your practice
• Record Keeping Recommendations [PDF]
• Office Buprenorphine/Naloxone Log (2 mg) [Word]―This chart helps your staff track your office inventory of this dose of SUBOXONE medication
• Office Buprenorphine/Naloxone Log (8 mg) [Word]―This chart helps your staff track your office inventory of this dose of SUBOXONE medication
• Complete Patient Management Checklist [PDF]―This document outlines the SUBOXONE treatment program in a simple, step-by-step format that will be easy for you and your staff to follow; it will be a helpful reference tool throughout the entire course of a patient’s treatment

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Working With Pharmacists

The pharmacy professional plays a key role in opioid dependence treatment by helping to ensure that prescriptions for SUBOXONE and other necessary medications are dispensed in a timely manner. These tools are designed to facilitate ongoing treatment.

• Appointed Pharmacy Consent Form [Word]―By signing this form, the patient authorizes you to disclose to the pharmacy that he or she is being treated for opioid dependence; the pharmacy is also authorized to contact you to discuss treatment
• Fax Cover Sheet [Word]―For your use, this sheet simplifies access to SUBOXONE from the designated pharmacy

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Working With Counselors

Successful treatment for opioid dependence with SUBOXONE includes counseling, which can help the patient to achieve cognitive and behavioral changes. These tools will help you work with counselors for optimum patient progress.

• Quality Care Therapy Progress Report [PDF]―This form should be completed by the patient, counselor, and physician to help monitor patient progress with SUBOXONE treatment

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SUBOXONE Treatment Resources

Patient Screening

Careful assessment through screening will help determine if a patient is an appropriate candidate for SUBOXONE medication. These materials will assist you with this process.

• Pretreatment Screening Assessment Tool [Word]―This sheet is for use by the staff member who first interviews the patient to determine if he or she is an appropriate candidate for SUBOXONE medication
• Drug Abuse Screening Test – DAST 10 [PDF]―This questionnaire guides physicians through screening patients for opioid dependence and ensuring that appropriate candidates receive treatment with SUBOXONE
• Drug Abuse Screening Test (DAST) – Long Version [Word]―This simple “yes or no” test helps to ascertain a patient’s substance misuse status to determine if he or she is a candidate for SUBOXONE medication

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Pre-First Visit & Intake

The likelihood of treatment success increases if all procedures and expectations associated with receiving SUBOXONE medication are conveyed to new patients, both verbally and in writing, before they begin treatment. Some of these handouts should be completed in your office; others should be given to patients prior to the first treatment visit.

For office use:

• Initial Patient Contact Form [Word]―This sheet offers guidance on how to respond when a patient calls your office seeking treatment for opioid dependence, and provides space to record pertinent patient information
• Quality Care Patient Intake Form [PDF]―This form focuses on previous and current substance abuse
• Patient Intake: Medical History Form [Word] [en Español]―This comprehensive form includes standard medical history criteria, as well as a section that focuses on previous and current substance use, dependence, and attempts at abstinence
• Patient Intake: Physical Exam Form [Word]―Using this form, you may enter information about the patient’s physical appearance as it relates to signs and symptoms of substance use
• Patient Intake: Social/Family History Form [Word] [en Español]―This form will help you to assess the patient’s familial and environmental situation, and gather information about previous attempts at substance abuse treatment
• Substance Dependence Assessment Form [Word]―This sheet focuses on the patient’s previous withdrawal symptoms and treatment, present illness, family history of substance abuse, and development of an individualized treatment plan

For the patient prior to the first treatment visit:

• Quality Care Induction Checklist [PDF]―checklist can be used to make sure that a patient completes all aspects of induction
• Methadone Transfer Consent Form [Word] [en Español]―Using this form, the patient taking methadone authorizes the outpatient treatment facility to release his or her records and confidential information to you as the treating physician
• Explanation of Treatment Handout [Word]―This sheet outlines each phase of the SUBOXONE treatment program
• Explanation of First Visit Handout [Word]―This sheet prepares the patient for the first office visit when he or she must bring a filled prescription of SUBOXONE medication; it underscores that he or she should be in withdrawal for this visit, and provides a handy checklist
• Patient Treatment Contract [Word] [en Español]―By signing this form, the patient agrees to comply with your directions and meet his or her obligations during the SUBOXONE treatment program
• Consent to Release/Receive Confidential Information [Word]―This form authorizes you to release or receive the patient’s confidential information to other healthcare professionals
• Telephone Appointment Reminder Consent Form [Word]―This form permits your staff to call the patient as a reminder about a scheduled appointment

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Induction Resources

When patients begin treatment they need to know what to expect in treatment and be thoroughly evaluated for treatment. The forms below can be used in evaluating patients during intake and induction.

• DSM-IV Criteria for Substance Dependence and Abuse [Word]―These medical and psychological criteria will help you to determine if the patient is an appropriate candidate for SUBOXONE medication
• DSM-IV Criteria for Dependence and Abuse: Diagnosis Worksheet [Word]―This document will assist with the diagnosis of a patient’s opioid dependence to determine if SUBOXONE medication is indicated
• Opioid Withdrawal Record [Word]―This form allows you to monitor the patient’s physiological signs and symptoms and SUBOXONE medication dosing over the course of treatment
• Home Dosing Record [Word] [en Español]―This form helps the patient keep track of taking SUBOXONE medication and other medications, as well as dosing over the course of treatment
• After-Hours Contact Information [Word] [en Español]―This form for patients provides contact information where you may be reached in case of an emergency

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Maintenance Resources

During the maintenance phase, patients should continue to be evaluated for progress and withdrawal symptoms. These forms can be used to help monitor patients.

• Quality Care Therapy Progress Report [PDF]―This form includes questions based on determining a patient’s progress in treatment. To get a thorough report, there are sections for the patient, counselor, and physician to fill out
• Appropriate Use Checklist [PDF]―This document serves as a reminder to monitor the appropriate use of SUBOXONE by offering a series of measures to be addressed during each patient’s appointment

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