Document Text Contents
Page 1
Medications for Opioid Use Disorder
TIP 63
TREATMENT IMPROVEMENT PROTOCOL
For Healthcare and Addiction Professionals, Policymakers, Patients, and Families
Page 2
This page intentionally left blank.
Page 153
Medications for Opioid Use Disorder
Part 3: Pharmacotherapy for Opioid Use Disorder
TIP 63
3-71
Sample Goal-Setting Form
Name: Date:
Category
Current Situation
Score (10 = major
problems and 0 = no
problems).
What Would Need To Change
To Decrease This Score?
Priority Score (10 =
highest priority [“I really
want to work on this.”]
and 1 = lowest priority
[“I really do not want to
work on this.”).
Opioid Use
Other Illicit Drug Use: ________
Alcohol Use
Tobacco Use
Physical Health
Mental Health
Legal/Court Issues
Finances
Job/Employment
Hobbies
Family Relations
Partner Relations
Supportive Drug-Free Network
Education
Keeping Medication Safe (e.g.,
not giving it away, selling it,
having it stolen)
Other:
Other:
M. Lofwall, February 27, 2017 (personal communication). Adapted with permission.
Buprenorphine Treatment Agreement
This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care.
Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of
their individual patients and practice arrangements. The information provided in this form is provided “as is” with no
guarantee as to its accuracy or completeness.
Treatment Agreement
I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:
1. The risks and benefits of buprenorphine treatment have been explained to me.
2. The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and
nonmedication treatments) have been explained to me.
3. I will keep my medication in a safe, secure place away from children (for example, in a lockbox). My plan is to store
it [describe where and how].
Page 154
TIP 63
Medications for Opioid Use Disorder
Part 3: Pharmacotherapy for Opioid Use Disorder
3-72
Buprenorphine Treatment Agreement
4. I will take the medication exactly as my healthcare provider prescribes. If I want to change my medication dose, I
will speak with my healthcare provider first. Taking more medication than my healthcare provider prescribes or
taking it more than once daily as my healthcare provider prescribes is medication misuse and may result in
supervised dosing at the clinic. Taking the medication by snorting or by injection is also medication misuse and
may result in supervised dosing at the clinic, referral to a higher level of care, or change in medication based on my
healthcare provider’s evaluation.
5. I will be on time to my appointments and respectful to the office staff and other patients.
6. I will keep my healthcare provider informed of all my medications (including herbs and vitamins) and medical
problems.
7. I agree not to obtain or take prescription opioid medications prescribed by any other healthcare provider without
consulting my buprenorphine prescriber.
8. If I am going to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so
that my pain will be adequately treated.
9. If I miss an appointment or lose my medication, I understand that I will not get more medication until my next
office visit. I may also have to start having supervised buprenorphine dosing.
10. If I come to the office intoxicated, I understand that my healthcare provider will not see me, and I will not receive
more medication until the next office visit. I may also have to start having supervised buprenorphine dosing.
11. I understand that it’s illegal to give away or sell my medication; this is diversion. If I do this, my treatment will no
longer include unsupervised buprenorphine dosing and may require referral to a higher level of care, supervised
dosing at the clinic, and/or a change in medication based on my healthcare provider’s evaluation.
12. Violence, threatening language or behavior, or participation in any illegal activity at the office will result in
treatment termination from the clinic.
13. I understand that random urine drug testing is a treatment requirement. If I do not provide a urine sample, it will
count as a positive drug test.
14. I understand that I will be called at random times to bring my medication container into the office for a pill or film
count. Missing medication doses could result in supervised dosing or referral to a higher level of care at this clinic
or potentially at another treatment provider based on my individual needs.
15. I understand that initially I will have weekly office visits until I am stable. I will get a prescription for 7 days of
medication at each visit.
16. I can be seen every 2 weeks in the office starting the second month of treatment if I have two negative urine drug
tests in a row. I will then get a prescription for 14 days of medication at each visit.
17. I will go back to weekly visits if I have a positive drug test. I can go back to visits every 2 weeks when I have two
negative drug tests in a row again.
18. I may be seen less than every 2 weeks based on goals made by my healthcare provider and me.
19. I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines
(drugs like Valium, Klonopin, and Xanax).
20. I understand that treatment of opioid use disorder involves more than just taking medication. I agree to comply
with my healthcare provider’s recommendations for additional counseling and/or for help with other problems.
21. I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is for me to
stop using all illicit drugs and become successful in all aspects of my life.
22. I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.
23. I have been educated about the other two FDA-approved medications used for opioid dependence treatment,
methadone and naltrexone.
24. I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting
buprenorphine treatment and been informed about methods for preventing pregnancy
Other specific items unique to my treatment include:
Patient Name (print): _________________ Patient Signature: ______________ Date: ____________________
This form is adapted from ASAM’s Sample Treatment Agreement, which they will update periodically; their most current version of the
agreement is available online (www.asam.org/docs/default-source/advocacy/sample-treatment-
agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0).
Adapted with permission.345
http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0
http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0
Page 305
Available TIPs
TIPs may be ordered or downloaded for free from SAMHSA’s Publications Ordering webpage at https://
store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
TIP 21 Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in the
Justice System
TIP 24 A Guide to Substance Abuse Services for
Primary Care Clinicians
TIP 27 Comprehensive Case Management for
Substance Abuse Treatment
TIP 29 Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities
TIP 30 Continuity of Offender Treatment for
Substance Use Disorders From Institution to
Community
TIP 31 Screening and Assessing Adolescents for
Substance Use Disorders
TIP 32 Treatment of Adolescents With Substance
Use Disorders
TIP 33 Treatment for Stimulant Use Disorders
TIP 34 Brief Interventions and Brief Therapies for
Substance Abuse
TIP 35 Enhancing Motivation for Change in
Substance Abuse Treatment
TIP 36 Substance Abuse Treatment for Persons
With Child Abuse and Neglect Issues
TIP 37 Substance Abuse Treatment for Persons
With HIV/AIDS
TIP 38 Integrating Substance Abuse Treatment and
Vocational Services
TIP 39 Substance Abuse Treatment and Family
Therapy
TIP 41 Substance Abuse Treatment: Group Therapy
TIP 42 Substance Abuse Treatment for Persons
With Co-Occurring Disorders
TIP 44 Substance Abuse Treatment for Adults in the
Criminal Justice System
TIP 45 Detoxification and Substance Abuse
Treatment
TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment
TIP 47 Substance Abuse: Clinical Issues in Intensive
Outpatient Treatment
TIP 48 Managing Depressive Symptoms in
Substance Abuse Clients During Early
Recovery
TIP 49 Incorporating Alcohol Pharmacotherapies
Into Medical Practice
TIP 50 Addressing Suicidal Thoughts and Behaviors
in Substance Abuse Treatment
TIP 51 Substance Abuse Treatment: Addressing the
Specific Needs of Women
TIP 52 Clinical Supervision and Professional
Development of the Substance Abuse
Counselor
TIP 53 Addressing Viral Hepatitis in People With
Substance Use Disorders
TIP 54 Managing Chronic Pain in Adults With or in
Recovery From Substance Use Disorders
TIP 55 Behavioral Health Services for People Who
Are Homeless
TIP 56 Addressing the Specific Behavioral Health
Needs of Men
TIP 57 Trauma-Informed Care in Behavioral Health
Services
TIP 58 Addressing Fetal Alcohol Spectrum
Disorders (FASD)
TIP 59 Improving Cultural Competence
TIP 60 Using Technology-Based Therapeutic Tools
in Behavioral Health Services
TIP 63 Medications for Opioid Use Disorder
TIP 61 Behavioral Health Services for American
Indians and Alaska Natives
TIP 62 Relapse Prevention and Recovery Promotion
in Behavioral Health Services
Upcoming TIPs
Page 306
HHS Publication No. (SMA) 18-5063FULLDOC
Printed 2018
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Medications for Opioid Use Disorder
TIP 63
TREATMENT IMPROVEMENT PROTOCOL
For Healthcare and Addiction Professionals, Policymakers, Patients, and Families
Page 2
This page intentionally left blank.
Page 153
Medications for Opioid Use Disorder
Part 3: Pharmacotherapy for Opioid Use Disorder
TIP 63
3-71
Sample Goal-Setting Form
Name: Date:
Category
Current Situation
Score (10 = major
problems and 0 = no
problems).
What Would Need To Change
To Decrease This Score?
Priority Score (10 =
highest priority [“I really
want to work on this.”]
and 1 = lowest priority
[“I really do not want to
work on this.”).
Opioid Use
Other Illicit Drug Use: ________
Alcohol Use
Tobacco Use
Physical Health
Mental Health
Legal/Court Issues
Finances
Job/Employment
Hobbies
Family Relations
Partner Relations
Supportive Drug-Free Network
Education
Keeping Medication Safe (e.g.,
not giving it away, selling it,
having it stolen)
Other:
Other:
M. Lofwall, February 27, 2017 (personal communication). Adapted with permission.
Buprenorphine Treatment Agreement
This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care.
Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of
their individual patients and practice arrangements. The information provided in this form is provided “as is” with no
guarantee as to its accuracy or completeness.
Treatment Agreement
I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:
1. The risks and benefits of buprenorphine treatment have been explained to me.
2. The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and
nonmedication treatments) have been explained to me.
3. I will keep my medication in a safe, secure place away from children (for example, in a lockbox). My plan is to store
it [describe where and how].
Page 154
TIP 63
Medications for Opioid Use Disorder
Part 3: Pharmacotherapy for Opioid Use Disorder
3-72
Buprenorphine Treatment Agreement
4. I will take the medication exactly as my healthcare provider prescribes. If I want to change my medication dose, I
will speak with my healthcare provider first. Taking more medication than my healthcare provider prescribes or
taking it more than once daily as my healthcare provider prescribes is medication misuse and may result in
supervised dosing at the clinic. Taking the medication by snorting or by injection is also medication misuse and
may result in supervised dosing at the clinic, referral to a higher level of care, or change in medication based on my
healthcare provider’s evaluation.
5. I will be on time to my appointments and respectful to the office staff and other patients.
6. I will keep my healthcare provider informed of all my medications (including herbs and vitamins) and medical
problems.
7. I agree not to obtain or take prescription opioid medications prescribed by any other healthcare provider without
consulting my buprenorphine prescriber.
8. If I am going to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so
that my pain will be adequately treated.
9. If I miss an appointment or lose my medication, I understand that I will not get more medication until my next
office visit. I may also have to start having supervised buprenorphine dosing.
10. If I come to the office intoxicated, I understand that my healthcare provider will not see me, and I will not receive
more medication until the next office visit. I may also have to start having supervised buprenorphine dosing.
11. I understand that it’s illegal to give away or sell my medication; this is diversion. If I do this, my treatment will no
longer include unsupervised buprenorphine dosing and may require referral to a higher level of care, supervised
dosing at the clinic, and/or a change in medication based on my healthcare provider’s evaluation.
12. Violence, threatening language or behavior, or participation in any illegal activity at the office will result in
treatment termination from the clinic.
13. I understand that random urine drug testing is a treatment requirement. If I do not provide a urine sample, it will
count as a positive drug test.
14. I understand that I will be called at random times to bring my medication container into the office for a pill or film
count. Missing medication doses could result in supervised dosing or referral to a higher level of care at this clinic
or potentially at another treatment provider based on my individual needs.
15. I understand that initially I will have weekly office visits until I am stable. I will get a prescription for 7 days of
medication at each visit.
16. I can be seen every 2 weeks in the office starting the second month of treatment if I have two negative urine drug
tests in a row. I will then get a prescription for 14 days of medication at each visit.
17. I will go back to weekly visits if I have a positive drug test. I can go back to visits every 2 weeks when I have two
negative drug tests in a row again.
18. I may be seen less than every 2 weeks based on goals made by my healthcare provider and me.
19. I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines
(drugs like Valium, Klonopin, and Xanax).
20. I understand that treatment of opioid use disorder involves more than just taking medication. I agree to comply
with my healthcare provider’s recommendations for additional counseling and/or for help with other problems.
21. I understand that there is no fixed time for being on buprenorphine and that the goal of treatment is for me to
stop using all illicit drugs and become successful in all aspects of my life.
22. I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.
23. I have been educated about the other two FDA-approved medications used for opioid dependence treatment,
methadone and naltrexone.
24. I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting
buprenorphine treatment and been informed about methods for preventing pregnancy
Other specific items unique to my treatment include:
Patient Name (print): _________________ Patient Signature: ______________ Date: ____________________
This form is adapted from ASAM’s Sample Treatment Agreement, which they will update periodically; their most current version of the
agreement is available online (www.asam.org/docs/default-source/advocacy/sample-treatment-
agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0).
Adapted with permission.345
http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0
http://www.asam.org/docs/default-source/advocacy/sample-treatment-agreement30fa159472bc604ca5b7ff000030b21a.pdf?sfvrsn=0
Page 305
Available TIPs
TIPs may be ordered or downloaded for free from SAMHSA’s Publications Ordering webpage at https://
store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
TIP 21 Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in the
Justice System
TIP 24 A Guide to Substance Abuse Services for
Primary Care Clinicians
TIP 27 Comprehensive Case Management for
Substance Abuse Treatment
TIP 29 Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities
TIP 30 Continuity of Offender Treatment for
Substance Use Disorders From Institution to
Community
TIP 31 Screening and Assessing Adolescents for
Substance Use Disorders
TIP 32 Treatment of Adolescents With Substance
Use Disorders
TIP 33 Treatment for Stimulant Use Disorders
TIP 34 Brief Interventions and Brief Therapies for
Substance Abuse
TIP 35 Enhancing Motivation for Change in
Substance Abuse Treatment
TIP 36 Substance Abuse Treatment for Persons
With Child Abuse and Neglect Issues
TIP 37 Substance Abuse Treatment for Persons
With HIV/AIDS
TIP 38 Integrating Substance Abuse Treatment and
Vocational Services
TIP 39 Substance Abuse Treatment and Family
Therapy
TIP 41 Substance Abuse Treatment: Group Therapy
TIP 42 Substance Abuse Treatment for Persons
With Co-Occurring Disorders
TIP 44 Substance Abuse Treatment for Adults in the
Criminal Justice System
TIP 45 Detoxification and Substance Abuse
Treatment
TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment
TIP 47 Substance Abuse: Clinical Issues in Intensive
Outpatient Treatment
TIP 48 Managing Depressive Symptoms in
Substance Abuse Clients During Early
Recovery
TIP 49 Incorporating Alcohol Pharmacotherapies
Into Medical Practice
TIP 50 Addressing Suicidal Thoughts and Behaviors
in Substance Abuse Treatment
TIP 51 Substance Abuse Treatment: Addressing the
Specific Needs of Women
TIP 52 Clinical Supervision and Professional
Development of the Substance Abuse
Counselor
TIP 53 Addressing Viral Hepatitis in People With
Substance Use Disorders
TIP 54 Managing Chronic Pain in Adults With or in
Recovery From Substance Use Disorders
TIP 55 Behavioral Health Services for People Who
Are Homeless
TIP 56 Addressing the Specific Behavioral Health
Needs of Men
TIP 57 Trauma-Informed Care in Behavioral Health
Services
TIP 58 Addressing Fetal Alcohol Spectrum
Disorders (FASD)
TIP 59 Improving Cultural Competence
TIP 60 Using Technology-Based Therapeutic Tools
in Behavioral Health Services
TIP 63 Medications for Opioid Use Disorder
TIP 61 Behavioral Health Services for American
Indians and Alaska Natives
TIP 62 Relapse Prevention and Recovery Promotion
in Behavioral Health Services
Upcoming TIPs
Page 306
HHS Publication No. (SMA) 18-5063FULLDOC
Printed 2018
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
