Establishing a Relationship with a Pharmacy
Ensuring Your Patients Have Access to Medication
You should establish a relationship with at least one local pharmacy before starting a buprenorphine practice to ensure that they can stock adequate supplies of buprenorphine.
Guidelines to Consider
Consider the following guidelines when contacting a pharmacy:
- Verify any time requirements that you have if you need the prescription filled quickly. This is especially important during buprenorphine induction.
- Specify which formulation of the buprenorphine/naloxone combination you will be using -- film or tablet, sublingual or buccal, and if you will specify a brand name.
- For the rare patient who is taking the monotherapy formulation, ensure that their preferred pharmacy has access to these tablets.
- Verify that the pharmacy can fill prescriptions quickly; this is especially important during induction when patients will visit the pharmacy to pick up single doses of buprenorphine.
- Ask the pharmacists if they are familiar with buprenorphine treatment and dispensing the medication and, if not, refer them to some educational materials.
- Ask the pharmacists to contact you to alert you if the patient is filling prescriptions for other controlled substances, requesting early refills, behaving inappropriately, claiming to have lost prescriptions, etc.
Have All Patients Sign a Pharmacy Consent
On a related note, you should have all patients sign a pharmacy consent form and keep this on file in case the pharmacy requires it for communications about the patient.
Name/Practice Name: ____________________________
City, State, ZIP: ________________________________________
APPOINTED PHARMACY CONSENT
I, ______________________________________________[Patient Name- Print], do hereby:
(MD check all that apply)
1) __ Authorize ________________________________[Provider Name- Print] at the above address to disclose my treatment for opioid
dependence to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my buprenorphine prescriptions directly to the
2) __ Agree to allow pharmacist to contact provider listed above to discuss my treatment if necessary so that my buprenorphine prescriptions can be filled and either delivered to the office addressed given above or picked-up by employees of the same.
I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken on reliance on it. This consent will last while I am being treated for opioid dependence by the provider specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the provider specified above is otherwise notified by me.
I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.
I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2, and I further acknowledge that I understand those rights.
_____________________ _________________________ __________
Patient Signature Patient Name (Print) Date
______________________ ___________________________ _________
Parent/Guardian Signature Parent/Guardian Name (Print) Date
______________________ ______________________________ _________
Witness Signature Witness Name (Print) Date
Appointed Pharmacy: Name: _____________________________Phone: ___________
Confidentiality of Alcohol- and Drug-Dependence Patient Records
The confidentiality of alcohol- and drug-dependence patient records maintained by this practice/program is protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient
as being alcohol- or drug-dependent unless:
1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation.
Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit
such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.