Patient: DOB: Date: Allergies: HOW TO STOP CURRENT MEDICATION 1. You meet detox criteria and withdrawal criteria to have induction today

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1 Suboxone induction instructions: Patient: DOB: Date: Allergies: Suboxone Induction Regimen for Addiction/Opiate Dependence Suboxone Induction Regimen for Addiction Relapse HOW TO STOP CURRENT MEDICATION 1. You meet detox criteria and withdrawal criteria to have induction today 2. You DO NOT meet criteria and have to come back in the morning or some other identified time for induction 3. This information is being given for training and planning for Opiate dependence after chronic opiate therapy for chronic pain condition, and possible Opiate induced Hyperalgesia. INDUCTION MEDICATION INFORMATION: SEE MARKED MEDICATIONS TO BE GIVEN A. Suboxone 8mg/2mg film or Suboxone 2mg/.5mg film

2 B. The prescription will be given as: one film every 8 hours one film every 12 hours C. Subutex 2mg pill was used or Subutex 8mg was used and dose frequency will be 1/2 or 1 whole every 8 12 hours D. The above dosing is to be followed for the first 7 10 days or until you are seen by the provider again. Max dose is 3 films per 24 hours. Mimimum advised dose is 1/2 (half) film under tongue every 12 hours E. Clonidine pills 0.1mg po every 12 hours as needed for aggitation or Clonidine TTS1 patch every 7 days * Take as ordered by the provider, unless blood pressure is too low or doctor advises otherwise F. High dose Vitamin C to dose up to 4000 to 5000mg daily to optimize withdrawal symptoms is advised. If you develop loose stool, reduce dose until it resumes normal G. Phenergan 25mg one po every 6 hours as needed for nausea or aggitation

3 PART 1 OF INDUCTION: BEGINS IN OFFICE TODAY OTHER DATE: INITIATION OF TREATMENT/LOADING DOSE PART 1: A. GIVEN 1/2 FILM/ FIRST DOSE TIME: Suboxone 8/2mg half of a film Suboxone 2/.5 half or whole film Subutex 2mg pill Subutex 8mg pill B. Given 2nd Dose/ Time: (20 30 mins after first dose) Suboxone 8/2mg half of a film Suboxone 2/.5 half or whole film Subutex 2mg pill Subutex 8mg pill * This dose is minutes after first dose under your tongue if you still feel any feelings of withdrawal like symptoms. This dose may have increased the withdrawal you were having, or it may be the only other dose you need to load the medication in your system or it completely resolved your withdrawal.

4 C. Given 3rd Dose/ Time: (20 30 mins after 2nd dose) Suboxone 8/2mg half of a film Suboxone 2/.5 half or whole film Subutex 2mg pill Subutex 8mg pill * This dose may not be indicated... and again is minutes after the second dose under your tongue, if you still felt any feelings of withdrawal like symptoms. This dose may have increased the withdrawal you were having, or it may be the only other dose you need to load the medication into your system, or it completely resolved your withdrawal. PART 2 INDUCTION DAY/STILL DAY ONE SCHEDULED DOSING 1. After the induction in the office is done you will begin daily doses as listed. 2. Your daily dose is determined by your provider and your response during induction. 3. Your next dose on the induction day is done at home, and is 6 8 hours from the very first dose given in the office by the provider. 4. YOUR NEXT DOSE IS: AT A. One full Suboxone 8/2mg film or Suboxone 2/.5 mg film B. Repeat one dose every 8 hours until you follow up with the provider (example of dose if FIRST LOADING DOSE WAS DONE AT 8AM THEN NEXT REGULAR DOSE IS DONE. NEXT SCHEDULED BY PHYSICIAN OR 6 HOURS LATER DOSE WOULD BE 2PM)

5 5. CONTINUE THIS DOSE AS PRESCRIBED. UNLESS THE DOSE MAKES YOU TOO SLEEPY. If symptoms of agitation and/or sweating, skin creepy crawling symptoms, or other agitation symptoms and not pain occur before the 6 hours is up you may use the Clonidine for that. If you are light headed or the medication makes you feel racing or high like, this is very rare and means you are extra sensitive to the dose, and you must reduce all doses by half and contact the office. If you are not sure what you are feeling you must stop using this medication and contact the office and report symptoms as URGENT and FROM NEW SUBOXONE INDUCTION PATIENT to the staff or if provided to you. PART 3 DAY AFTER YOUR LOADING DOSE/SCHEDULED DOSE Suboxone 8mg/2mg 1/2 film under your tongue as prescribed You may need the Clonidine in between the Suboxone/Subutex doses Keep appointment for follow up Manditory Counseling providers that we use frequently are mandatory for program long term Recommend Counseling HERE TO HELP MODULES Begin them HERE TO HELP PROGRAM: You must also register for the program, which is FREE with the drug company who makes the Suboxone product. This is an online registration. (THIS IS MANDATORY) The Here to Help Program Resources The Here to Help Program website HeretoHelpProgram.com delivers guided support to help patients: patients can call HERE (4373) for help finding counseling options in their area. https://www.suboxone.com/patients/here_to_help/register/registration_step1.aspx

6 * Develop the skills to reinforce your successful recovery * Access additional resources that can help you understand and manage your disease Heretohelpprogram.com is uniquely designed to provide customized and guided support to you through many of the situations you may face during treatment, including: * Continuing to Grow Guided learning activities designed to keep patients engaged and active participants in their treatment. Key skills and topics include "Managing Stress," "Responding to Difficult Situations," and "Keeping Motivation" * My Recovery is at Risk By answering 5 essential questions, patients can quickly understand and evaluate risk factors that could interfere with their success in treatment. patients can return to this section whenever they feel their recovery is at risk. * Creating Personal Solutions Interactive tools to help patients create action plans to support their recovery. Action plans include "Managing Triggers and Risky Situations," "Setting Goals for Change," and "Strengthening Relationships." * Finding Answers Provides easy to understand information on topics patients want and need to know about their disease and treatment, including "Opioid dependence as a chronic disease," "What to expect during treatment," and "How to be Prepared in the event of a setback" * I've had a Setback Provides patients with essential guidance to help them get back to treatment after a slip or a relapse Each section is customized based on patient response. Patients can print or save their action plans and exercises to refer to offline or to share with their treatment

7 providers Ashley Oaks Circle Wesley Chapel, FL ph fx THIS IS A MANDATORY REGISTER (IT IS FREE). THIS IS AN ONLINE REGISTRATION. YOU WILL BE MANDATED TO BRING BACK THE CONFIRMATION OF REGISTRATION AND SUBSEQUENT VISITS OR DISCUSSION NOTES FOR THE CHART TO SHOW COMPLIANCE. IF YOU DO NOT BRING BACK THE INITIAL REGISTRATION YOU MAY JEOPARDIZE THE QUANTITY OF SUBOXONE YOU WILL BE GIVEN AT ONE TIME. I.E... YOU MAY ONLY GET ONE DAY'S MEDS, ETC. REMS DISCUSSION This checklist: (Courtesy of Reckitt Benckiser Manufacturer of Suboxone film and tablets): As a healthcare provider who prescribes SUBOXONE (buprenorphine and naloxone) sublingual film CIII, SUBOXONE (buprenorphine and naloxone) sublingual tablets CIII, or Subutex (buprenorphine) sublingual tablets CIII, this checklist is a useful reminder of the safe use conditions and monitoring requirements to be addressed during each patient's appointment. These include: 1) understanding and reinforcement of safe use conditions, 2) the importance of psychosocial counseling, and 3) screening and monitoring patients to determine progress toward treatment goals. If a patient continues to abuse various drugs or is unresponsive to treatment, including psychosocial intervention, it is important that you assess the need to refer the patient to a specialist and/or more intensive behavioral treatment environment. Additional resource: Clinical Support System: Measurement to Ensure Appropriate Use Induction Verified patient meets diagnostic criteria for opioid dependence Discussed risk described in professional labeling and Medication Guide with

8 patient Explained or reviewed conditions of safe storage of medication Provided induction doses under appropriate supervision Prescribed limited amount of medication at first visit Scheduled next visit at interval commensurate with patient stability * weekly or more frequent visits are recommended for the first month if YOU HAVE SIDE EFFECTS NOT LISTED OR WERE NOT DISCUSSED, PLEASE CONTACT THE OFFICE AT Jose de la Torre, MD NEW TAMPA INTERVENTIONAL PAIN AND SPORTS MEDICINE, INC. COUNSELORS TO CHOOSE FROM (also look at your insurance listing of counselors): Addiction Counseling/ Therapists: Resource link: borough&state=fl&spec=4 Psychologists: Achieve Wellness Group W. Linebaugh Ave Building 5, Suite #101

9 Tampa, FL Kristin Keough PsyD, LCPC, CADC Karen M Milo, PhD Psychology Center of Tampa Bay North 56th St Tampa, FL Office # Brad Palermo PsyD Psychology Addiction treatment COUNSELORS: Back to Work Counselors Brandon, FL Dan Cosby Independent Counselor Mr. M. Shawn Kellerman Counselor, LMHC, SAP, MAC, CAP, ICADC st Ave North Ste # 6W Saint Petersburg,FL Additional office on Hobbs Street in Tampa Saralee H Fackelman Counselor, MS, LMHC, CAP

10 THe Life Center 6811 N. Central Ave Tampa, FL John J. Bosworth Counselor, MA, LMHC 5201 W. Kennedy Blvd. Ste # 708 Tampa, FL Additional office in Clearwater Pathworks Workshop, PA Counselor Pathworks Workshop,PA 4144 N Armenia Ave Ste 301 Tampa Dr. Douglas Uzzell PhD, LMHC, CAP SOCIAL WORKERS: Mark Davis Davis Sound (another favorite of mine in North Tampa) 3820 Northdale Blvd 312B

11 Dr. Stacie Lauro Berlowitz Psychiatrist, MD,APBN Psychiatry Specializing in You 4320 W El Prado Blvd Tampa FACILITIES: petersburg/ Fairwinds Treatment Center 1569 South Fort Harrison Ave Clearwater Fairwinds Treatment Center is no addiction treatment center serving PINELLAS county and the city of Clearwater. The primary focus of Fairwinds Treatment Center is a mix of substance abuse and mental health services. They provide hospital inpatient, residential short term treatment (less than 30 days) services for detoxification, substance abuse treatment... TOWN AND COUNTRY HOSPITAL Odessa 6601 Webb Road Tampa ACTS 3170 North 50th St Tampa WestCare Gulfcoast Florida, Inc Central Ave St. Pete, FL WestCare Gulfcoast Florida Inc. is an addiction treatment center serving PINELLAS county and the city of St. Petersburg. The primary focus of WestCare Gulfcoast Florida, Inc is a mix of substance abuse and mental health service. They provide residential long term treatment (30

12 days or more) services for substance abuse treatment including drug addiction and alcohol... WestCare Florida Inc MLK Street South St Petersburg, FL Westcare Florida, Inc is an addiction treatment center serving PINELLAS county and the city of St. Petersburg. The primary focus of WestCare Florida Inc is substance substance abuse treatment services. They provide outpatient services for substance abuse treatment including drug addiction and alcohol addiction. They have treatment programs and services for adolescents... Gulf Coast Jewish Family Services Inc th Street North Saint Petersburg,FL GulfCoast Jewish Family Services Inc is an additional treatment center serving PINELLAS county and the city of St Petersburg. The primary focus of Gulf Coast Jewish Family Services, Inc is a mix of substance abuse and mental health services. They provide residential long term treatment (30days or more) services for substance abuse treatment including drug addiction and... Boley Centers for Behav Healthcare Inc Wild Acres Road Largo, FL Boley Centers for Behav Healthcare, Inc is an addiction treatment center serving PINELLAS county and the city of Largo. THe primary focus of Boley Centers for Behav Healthcare Inc is a mix of substance abuse and mental health services. They provide residential long term treatment (30 days or more), outpatient services for substance abuse treatment including drug... PSYCHIATRISTS: Dr. Sheehan Drs. Edson, Singh, De Ganuza, Sheehan, MDs North Dale Mabry Highway Tampa Dr. Linda A. Lefler, MD St. Petersburg, FL Addiction Psychiatry

13 Dr. Syed K. Zaidi, MD St. Petersburg, FL Addiction Psychiatry Dr. Bruce Welch, MD St. Petersburg, FL Addiction Psychiatry Suncoast Center Community Mental: Dr. Jackson, MD 4024 Central Ave. St Petersburg

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