Bevel Health Medical Group

MEDICATION ASSISTED TREATMENT PROGRAM

Policies and Procedures

The Medicated Assisted Treatment program or MAT was created by Bevel Health Medical Group and is modeled after the COAT program at West Virginia University Department of Behavioral Medicine. This is a medication assisted treatment program for patients with opioid use disorders (SUD). Opioids include both prescription medicines obtained by prescription or bought off the street as well as illicit opioids such as Heroin or Fentanyl. The program and MAT in general has been proven to be very effective in helping people attain long term recovery when patients are full partners in the treatment process and the rules and standards of the program are strictly adhered to. 

The program has four basic parts:

1. Doctor/Provider visits with patients with Opioid drug use disorders and the prescribing physician and, at times, other members of the MAT team. This visit is followed by counseling sessions and/or counseling course work that focus on relapse prevention as well as other topics relevant to continued abstinence from all drugs of abuse as well as alcohol. 
2. Individual psychotherapy includes meeting with a counselor one-on-one or participating in online coursework sessions that focus on the topics of addiction recovery, relapse prevention, abstinence, and other drug use prevention measures.

1. Prescriptions for Suboxone are provided with only sufficient medication to last until the next sessions with the physician and addiction counselor. 

1. Agreement to adhere to all program rules including remaining free of all controlled and illicit chemicals as well as alcohol, submitting to urine drug testing, both scheduled as well as random, not misusing the medication, NOT diverting any medication for illegal sales of the medication and observing confidentiality of all other patients participation in the program. 

To participate in the MAT Program: People are eligible for participation in the MAT program if they are a patient at Bevel Health Medical Group and they are referred to the program by their primary care provider, friend, family member, mental health specialist, or other medical or behavioral health provider.. 

Prospective patients will have an initial session with our staff to verify that the criteria for Opioid Dependence are met as well as to provide other program staff with the patient’s medical and drug use history and to ascertain the patient’s reason(s) for seeking treatment at the present time and to determine whether the program is appropriate for the patient. 

Signature below indicates that the particulars of the Bevel Health Medical Group Medication Assisted Treatment have been explained to you and you fully agree to the terms outlined above specifying the requirements of the program

Purpose and goals of treatment:

1. I understand that the long-term goal of this treatment is to remain drug and alcohol free and to build a foundation of recovery that allows me to completely change my life.
2. I will abstain from the use of other addictive substances; including alcohol, marijuana, and all other legal and illegal substances. I understand that continuing to use other substances is potentially deadly and may result in the treatment team referring me to a higher level of care/treatment or discontinuing my treatment with Buprenorphine at this MAT program.

Treatment Requirements:

1. I will attend the clinic as required and scheduled. I understand the MAT Clinic consists of Medical Management Appointments, Group Therapy Appointments, and Individual Therapy Appointments as required by law and by the MAT team. Attendance is required for each appointment unless I have notified the treatment team in advance of my need to miss an appointment and I am eligible for a makeup appointment. I recognize once I have established a solid recovery program, my clinic attendance may be reduced to every two weeks or once a month after an extended period of time of successful participation in the program with the understanding that this agreement will still apply.
2. . I understand that the treatment team may require that I attend meetings each week. Failing to follow through on my meeting attendance may result in termination of my treatment in the clinic.
3. I understand that I will be asked about Hepatitis C as well as other communicable diseases and other relevant laboratory tests as required by the treatment team. If I test positive for Hep C I will comply with Hep C follow up appointments and/or referrals.

Attendance

1. I will keep and be on time for all my scheduled appointments.
2. If an emergency arises, I will call the call center to inform the office at (412) 569-4300 or email support@bevelhealth.com. I must call to cancel at least two hours before my scheduled appointment. The above makeup policy applies.
3. I understand that a canceled appointment may result in my not being able to get my medication/prescription until the next scheduled visit.
4. I understand that an unexcused missed appointment or “no showing” an appointment may result in my being terminated / suspended or referred out of the program.
5. Cancellations 2 weeks in a row may result in termination from treatment. If terminated from the program for any reason, I must wait 30 days to reapply for treatment or longer depending on the waiting list. Readmission to the MAT program is always at the discretion of the MAT Team.

Payment

1. If there is a co-payment or charge I will pay my fee on the day of the service. (Copayment amounts are determined by the patient’s type of insurance coverage and patients will be provided information on anticipated charges (if any) at the time of enrollment.) Failure to pay for services, without prior payment arrangements, may result in suspension or termination from the program or referral to an indigent care program.

Use of Medicine:

1. 1. I will take my Buprenorphine as my doctor has instructed (place under tongue until dissolved) and not to alter the dose or the way I take my medication. If I am required to come to the clinic, for any reason, for a daily prescription I understand that my dose for that day will be taken at the clinic and the dosing will be witnessed by a MAT team member. 
   2. I will not sell, share, trade, or give away any of my Buprenorphine or any other prescription medication. I understand that such mishandling of my medication is a serious violation of this agreement as well as illegal and will result in my treatment being terminated without any recourse for appeal.
   3. I understand prescription brand Suboxone contains an opioid (Buprenorphine) that can be a target for people who abuse prescription medication or street drugs. I understand that the medication I receive is my responsibility and that I agree to keep it in a safe, secure place and protect it from theft. I understand that replacement prescriptions for lost or stolen medication will likely not be provided. The lost or stolen medication policy also applies. Also, written prescriptions will have no refills.
   4. Medication should be kept out of sight and reach of children. Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. If a child is exposed to your medication, medical attention should be sought immediately, even if the child has no symptoms and appears to be OK. 
   5. I will tell my treating physician about ANY other medications I receive from any doctors, dentists, and/or pharmacies. I understand it is my responsibility to tell all treatment providers about my participation in the MAT program and taking ANY medication that is addictive without prior authorization from the treatment team may result in my termination or suspension from the program.

• I understand mixing Buprenorphine with other medication, especially benzodiazepines, (for example Valium, Klonopin, Xanax, Ativan) and other Central Nervous System depressants (including alcohol) can be dangerous and even lethal. I have been informed that deaths have occurred from mixing Buprenorphine and benzodiazepines.

1. I understand that I will use one pharmacy for filling the medications prescribed as part of the addiction treatment program. 
2. Filling any controlled substance, such as Tramadol and/or Ambien, without first obtaining approval from the treatment team, may result in my immediate discharge or suspension from the program. Board of Pharmacy records will be monitored regularly. A LIST OF CONTROLLED SUBSTANCES IS PROVIDED ON A SEPERATE FORM.

Conduct in Clinic

1. I will conduct myself in a courteous manner and not engage in any illegal or disruptive activities on the clinic or pharmacy property. If I do not adhere I put myself at risk of being discharged.
2. I will provide my own urine for random drug screens as requested. Random urine drug screens will be observed. I understand that I have 30 minutes from my scheduled arrival time to provide a urine sample. I understand that tampering with, buying, selling, or otherwise procuring urine will result in my immediate termination from treatment as it is an admission of a dirty urine. I also understand I am subject to random breathalyzer screens and film / package or pill counts. I have 24 hours to report once contacted for a random pill/film count and or any other requested assessment. The only exception to this rule is agreeing to arrive within 2 hours if called on a Monday morning. Failure to comply may result in being discharged from the clinic.
3. . I understand bringing any children to my appointments is prohibited. It is my responsibility to find arrangements for my children to be watched while in my appointments. If this becomes an issue that results in my missing my appointments, I understand it may result in my discharge from the program.
4. I understand USAGE OF TOBACCO and/or NICOTINE PRODUCTS IS PROHIBITED while on clinic property. Failure to comply may result in immediate termination or suspension from the program.

Confidentiality:

1. I understand that those I see and what I hear in treatment is strictly confidential. Violation of confidentiality will likely result in immediate discharge and may subject me to other penalties and sanctions as prescribed by laws and regulations governing the protection of individual confidential information.
2. Confidentiality extends to all forms of social media. Any posting on Facebook, Twitter or any other social media about any participation in the MAT program is strictly forbidden and any mention of any other patient or participant of the MAT program is a blatant violation of patient confidentiality and will result in immediate discharge may subject me to other penalties and sanctions as prescribed by laws and regulations governing the protection of individual confidential information
3. I understand that my health issues may be discussed in the group, especially as it pertains to drug-related complications. For this manner of openness within the group, 

I give consent ________ for sharing of my information.

I do not give consent _________ for sharing of my information. 

I have read and understand the above agreement and my questions have been addressed. I received a copy of this agreement.

I have also received copies of the following forms:

• Copy of consent
• Hepatitis C information
• Prohibited Drug list while in MAT
• Benzodiazepine practice
• Make-up policy
• Urine drug screen policy
• Lost or stolen medication policy
• Voluntary and Involuntary withdrawal policies
• Social Media policies
• My relapse prevention plan
• Patient Rights information

BENZODIAZAPINE USE POLICY

• If a patient arrives for a first intake appointment and the urine drug screen is positive for Benzodiazepine’s, the patient will not be started on Suboxone given the risk of this combination of medications. The patient may come one time to be screened before next appointment and can receive a prescription for Suboxone if the urine drug screen is negative for Benzodiazepines. If the UDS is still positive, the patient must then wait until next appointment to be screened again.
• If at any point, a patient tests positive for Benzodiazepines but denies using, the patient may be given the previously planned prescription. However, if Benzodiazepines are confirmed, the patient will likely be suspended from the clinic for up to 30 days.
• If the patient screens positive for Benzodiazepines and admits to using, the following applies:
  • If a patient is already established in the MAT Program and receiving medication but screens positive for Benzodiazepines, the patient will must come back the next day to complete another UDS but will not be given a prescription for Suboxone given the risk of the combination of these two medications. The patient will continue to come for daily UDS until the patient screens negative for Benzodiazepines. Once screened negative for Benzodiazepines the patient will receive a prescription for Suboxone sufficient to last until the next appointment.
    • If the patient lives a distance away, he/she will have the option of taking an order for a UDS to a local facility to be performed the following day. The patient then comes to the clinic when the UDS is negative for Benzodiazepines. When an outside facility performs a UDS, the facility must fax the results to the MAT Clinic in order for the patient to get his/her prescription for the balance of medication to last until the patient’s next scheduled appointment.

NOTE: This policy is at the discretion of the doctor and may be modified at any time.

INVOLUNTARY WITHDRAWAL PROCEDURE

When a patient involuntarily withdrawals (is dismissed) from the program, it can be for various reasons:

1. Multiple relapses (depending on how often the relapses occur and on what substance the patient relapses) which are indicative of the need for a more intensive level of treatment and appropriate referral options will be provided.
2. Continual use of benzodiazepines which constitutes a serious health risk. Continued use of benzodiazepines, as with other repeated relapses, is indicative of the need for a more intensive level of treatment and appropriate referral options will be provided.
3. Continual misuse of alcohol constitutes a serious health risk and, as with other repeated relapses, is indicative of the need for a more intensive level of treatment and appropriate referral options will be provided.
4. Continual use of marijuana, as with other repeated relapses, constitute repeated relapses and are indicative of the need for a more intensive level of treatment. Should the program physician and the MAT team determine, with the patient’s input, that withdrawal from the MAT program is best, appropriate referral options will be provided.
5. Habitual absences from group meetings, both in the clinic and 12 step meetings, are a violation of the program rules that were agreed upon during the admission process. Various treatment alternatives will be provided for you to choose from and recommendations will be provided. A referral will be done for you.
6. Missing individual counseling sessions repeatedly which are a violation of the program rules that were agreed upon during the admission process. Various treatment alternatives will be provided for you to choose from and recommendations will be provided. A referral will be done for you.
7. Missing a random drug screen or any occurrence or information which leads to serious suspicions of diversion or misuse may result in involuntary withdrawal. Generally, no taper will be given during the process of offering a referral to another appropriate program. or if there is other information which is suspicious for diversion or alcohol misuse
8. Being abusive or disrespectful to the staff or other patients which is completely unacceptable and are a violation of the program rules that were agreed upon during the admission process. Various treatment alternatives will be provided for you to choose from and recommendations will be provided. A referral will be done for you, but any provider you select will be advised of the reason for your dismissal from the MAT program.

The dismissal is always at the discretion of the physician and the MAT team. You will be provided with a 7 day supply of their current dose of Suboxone with the understanding that this is their “tapering dose” and that this prescription should be used to slowly taper themselves off Suboxone. As you have been provided with a list of alternative treatment providers, unless a referral was arranged for you with an initial appointment scheduled, you will immediately begin to identify another Suboxone or comparable MAT program to enter into. If Intensive Outpatient Treatment or Residential Treatment was recommended for you, MAT staff can assist you in identifying an appropriate program if you have not chosen one upon dismissal from the program. No tapering dose will be written for patients who relapse on benzodiazepines because of the risk of death when Suboxone and benzodiazepines are used together. A detoxification referral will be offered to you and arrangements will be made for your admission. 

You will be provided with a prescription for naloxone. Many health departments offer a 30 minute training for Naloxone and provide free Naloxone during the training. Call your local health department for information.

Readmission to the MAT Program is always at the discretion of the MAT Team and can be discussed with you should you so desire

Medical Withdrawal

When a patient voluntarily withdraws from the MAT Program, it can be for various reasons: 

1. The patient has chosen to titrate their dose of Buprenorphine down gradually and has decided to discontinue the medication all together.
2. The patient has reasons such as work or school that necessitates that Buprenorphine be discontinued.

Medical withdrawal occurs as a voluntary and therapeutic withdrawal in accordance with approved national guidelines. In some cases, the withdrawal may be against the advice of clinical staff or against medical advice yet the patient wants or needs to discontinue Buprenorphine.

The MAT program shall supply a schedule of dose reduction well tolerated by the patient. The program shall continue to offer supportive treatment, including increased counseling sessions and recommendations for 12-self groups or other counseling services as appropriate. The MAT Director and Medical provider will work with the patient to devise a plan for gradually decreasing doses of Buprenorphine until the dose of medication is low enough that cessation of the medication will not result in severe withdrawal symptoms and / or induce cravings.

If the patient leaves the MAT program abruptly against medical advice, the program may re-admit the patient within 30 days without a formal reassessment procedure. However, the program must perform a physical assessment and a biopsychosocial assessment upon readmission after 30 days of departure. The program shall document attempting to assist the patient with any issues which may have triggered his or her abrupt departure.

The MAT program shall offer continuing care of each patient following the last prescription given for Buprenorphine. The patient will be encouraged to continue with counseling as warranted and agreed to by the patient and their primary therapist for any length of time needed and desired by the patient.

Re-entry to maintenance treatment will be available to the patient who has voluntarily withdrawn if the patient feels at risk for relapse or a relapse has occurred or if the patient has reconsidered withdrawal and decided voluntary withdrawal is not in their best interest.

Female patients shall have a negative pregnancy screen prior to the onset of medically supervised withdrawal. Should a pregnant patient decide to voluntarily withdraw from the MAT program, the patient will be advised of the potential impact on the fetus as well as the risks for themselves. Should a pregnant patient decide to withdraw against medical advice, the dose will be gradually titrated in accordance with approved national guidelines for pregnant patients.

The MAT program shall provide an individually tailored detailed relapse prevention plan developed by the primary counselor in conjunction with the patient and in accordance with approved national guidelines. The prevention plan shall be given to the patient in writing prior to the administration of the final dose of medication.

Lost or Stolen Medication Policy

If a patient’s Medication / Prescription is lost or stolen, the following applies:

1. The patient must provide a police report if the medication is stolen and the following provisions may also apply at the discretion and clinical judgment of the Program Medical Director and the MAT team.
2. If the police refuse to provide a police report about the stolen medication, a signed statement, including the officer’s badge number, from the police stating that a stolen medication report will not be completed.
   1. If the patient is currently scheduled for weekly clinic visit, the patient may either be required to go without medication for a week or be offered a prescription that they would have to pay for out-of-pocket as insurance will not pay for this medication
   2. If the patient is currently scheduled for bi-weekly visits to the clinic, he or she may have to go without medication if the next scheduled appointment is less than a week from the date of lost medication. If the patient’s next scheduled appointment is more than 7 days from the date of report, the patient may be required to go without medication until 7 days prior to the next scheduled appointment at which time medication will be provided daily for the balance of the remaining week, with the patient being required to check in daily. If a patient does not check in daily, either by reporting or calling in, the patient may then be discharged from the program.
   3. If the patient is currently scheduled for monthly visits to the clinic, he or she may be required to go without medication until one, two or three weeks prior to the next scheduled appointment. At that point, the patient will be required to check in either daily or weekly until the next scheduled appointment. Sufficient medication will be provided until the next required visit for the remainder of the time until the scheduled appointment. If a patient does not check in daily or weekly as required, either by reporting or calling in, the patient may then be discharged from the program.
3. The patient will be drug tested at the time of the report of stolen or lost medication. If the patient provides a clean UDS, the patient will not be considered to have relapsed and days clean will remain as is. If the UDS tests are dirty with any drug other than Buprenorphine, the patient will have relapsed and the policy for a dirty urine drug screen will apply.

*NOTE: The above policy does not pertain to pregnant patients. Please see below:

• If the patient is pregnant and reports medication being stolen, she must provide a police report or a signed statement from the police as described above.
• For a pregnant woman, follow the police report or signed statement, the patient will receive enough medication until the next scheduled visit. Daily or weekly check-ins may be required, with medication being provided that is sufficient until the next required visit.

MAT Social Media Policy

This policy is intended to help MAT patients make appropriate decisions about the use of social media such as blogs, wikis, social networking websites, podcasts, forums, message boards, or comments on web-articles, such as Twitter, Facebook, LinkedIn or other social media websites.

This policy outlines the standards we require MAT patients to observe when using social media, the circumstances in which we will monitor your use of social media and the action we will take in respect of breaches of this policy.

This policy covers all patients. Patients who are active in treatment, including but not limited to weekly, bi-weekly, monthly, and bi-monthly patients and patients who have left the program or who have been dismissed from the program for any reason.

The Scope of the Policy

All patients are expected to comply with this policy at all times to protect the privacy, confidentiality, and interests of MAT patients, both current and former. 

Breach of this policy will be dealt with on a case by case basis and, in serious cases, may be treated as gross misconduct leading to dismissal from the MAT program. Failure to adhere to this policy, whether active or inactive in the MAT, program may result in deleterious action. 

Implementation of the Policy

Implementation of this policy is effective upon the signature of the patient and becomes the responsibility of the patient

Prohibited on social media:

1. Use of a current or former patient’s name, or other identifiable feature, in connection with their participation with this treatment program. 
2. Use of a current or former employee’s name, or other identifiable feature, in connection with a current or former patient’s name, or other identifiable feature, with this treatment program.
3. Any statement which is likely to create a liability (whether it be criminal, civil and whether it be for you or for the MAT program).
4. You are personally responsible for content you publish into social media tools – be aware that what you publish will be public for many years.
5. If you are aware of any misuse of social media by other patients in the MAT program that are in breach of this policy please report it to the Care Coordinator or your counselor.

MAT Patients with Co-Occurring Disorders

Identifying and Helping Patients with Co-Occurring Substance

During the initial assessment process with new MAT patients, all patients will be screened for co-occurring mental health disorders. Patients will also be routinely re-assessed for mental health issues that occur in combination with a SUD. Given that improvements in the SUD with an accompanying mental health issue cannot occur without treating both issues concurrently, CCHC will use the four quadrant model of treatment endorsed by SAMHSA.

Identifying Patients with Co-Occurring Disorders

Medical providers, such as our organization, are in an excellent position to help their patients with both SUDs and MDs. These disorders may exacerbate or be related to not only each other but other mental health or health problems such as hepatitis, cirrhosis, depression, obsessive-compulsive disorder or bipolar disorder so patients with CODs may often be identified initially by the MAT program. Hence, the CCHC MAT providers, who have established relationships with their patients, will discuss these SUDs and MDs and the treatment plans.

Patient History & Screening

In order to identify patients with CODs, all patients will complete an initial mental health history and substance abuse history, including an ASAM assessment, the PHQ-9, GAD-7, the Mental Health Screening Form-III, and Adverse Childhood Experiences questionnaire. The MAT providers will ask questions about the results of these initial assessments and will use the scores as part of treatment.

Treatment for Patients with Co-Occurring Disorders as part of the MAT program

All patients who screen positive for a COD need a thorough assessment of any mental health disorder that has been potentially identified. The Quadrants of Care Model, a framework that classifies persons with CODs into four basic groups based on symptoms and relative symptom severity, helps determine appropriate patient care based on the type and severity of the patient’s symptoms (see exhibit 1). The quadrants and treatment protocols are as follows:

• • Quadrant I – Less severe mental illness and substance use/MAT: Primary health care setting/ 
  • Quadrant II – More severe mental illness and less severe substance use/ Probable collaboration with a traditional mental health provider who can prescribe psychotropic medications.
  • Quadrant III – More severe substance use and less severe Mental illness/ Mental Health or Substance /MAT: Primary health care setting/ 

• • Quadrant IV – More severe substance use and mental illness/ Mental Health System/ Integrated Services with Probable collaboration with a traditional mental health provider who can prescribe psychotropic medications.

 Procedure for Urine Drug Screen/Chain of Custody

New patients and patients are drugged screened in the following manner:

1. Drug screening cup will be mailed to the patient
2. Patient will open package in front of one of our staff members
3. Staff will verify that the screening cup is not tampered with.
4. Patient will provide a urine sample.
5. Results will be documented within one minute.

MAT Program

 Procedures for Diversion Control

When a patient is scheduled to begin our MAT program a Board of Pharmacy report is obtained by the physician or a designated staff member. All prescriptions on the report are verified to ensure that the patient is not obtaining suboxone from another source or other prescriptions that may interfere with beginning a suboxone treatment regime. If there are questions regarding the report the physician questions the patient before prescriptions are written. 

The patient will be instructed that each time they come into the clinic for a random urine drug screen or an appointment of any kind, they are to bring their prescription bottle.

Bevel Health Medical Group will establish partnerships to be able to provide consistent and reliable drug screenings to reduce the possibility of diversion. Bevel Health Medical Group may contact WBK Healthcare Services and Quest Diagnostics to collect urine samples from patients. We will require patients to submit a urine screening at minimum, once every four weeks. Patients will be randomly notified and given 24-48 hrs to show up at one of our desired locations.

In partnership with Bevel Health Medical Group, patients will be given a 24-48 hours notice to provide a urine sample. Patients will be monitored by the staff to ensure that the possibility of diversion is reduced or eliminated. The integrated urine drug tests provide up to 99% accurate results in just a matter of minutes. Each test is CLIA Waived, FDA Cleared, and CE Marked. Patients will be given both an instant test for immediate confirmation. The results will then be sent out to a lab to further confirmation. The results of the test will be followed up with the patient at their next visit.

In partnership with Quest Diagnostics we will require patients to submit random urine screenings at a minimum of every four weeks. Patients will be notified randomly and given 24-48 hours to visit a Quest Diagnostics location to provide a urine sample. Quest Diagnostics will provide further confirmation through use of their comprehensive laboratory. 

All urine test results will be electronically sent to the physician’s office through an electronic database called Quanum. The database is owned and managed by Quest Diagnostics and allows the provider to log in to see all information related to the urine test. Not only does it provide “positive and negative” results, but it also provides the provider with the “levels” that the positive drugs were present at. The “levels” also allow for greater clinical judgment, for example, it shows us whether the patient is consistently taking their medication.

Often, patients will confidentially share with MAT team members information about program rule violations by other patients. This information is shared with all team members. After verification that the information about rule violation is true, each individual situation is handled according to the doctor’s medical judgment whether or not termination from the MAT program is warranted.

In addition to the above mentioned procedures that are intended to prevent diversion of medication used in the MAT program, medication dosing is begun and maintained at the lowest possible effective dose, thus discouraging patients from lowering their own doses and diverting saved partial doses for sale.

The Stages of Relapse

Relapse is a process, it’s not an event. In order to understand relapse prevention you have to understand the stages of relapse. Relapse starts weeks or even months before the event of physical relapse. In this page you will learn how to use specific relapse prevention techniques for each stage of relapse. There are three stages of relapse.

• Emotional relapse
• Mental relapse
• Physical relapse

Emotional Relapse

In emotional relapse, you’re not thinking about using. But your emotions and behaviors are setting you up for a possible relapse in the future. 

The signs of emotional relapse are: Restless, Irritable and Discontent

• Anxiety
• Intolerance
• Anger
• Defensiveness
• Mood Swings
• Isolation
• Not asking for help
• Not going to meetings
• Poor eating habits
• Poor sleep habits

The signs of emotional relapse are also the symptoms of post-acute withdrawal. If you understand post-acute withdrawal it’s easier to avoid relapse, because the early stage of relapse is easiest to pull back from. In the later stages the pull of relapse gets stronger and the sequence of events moves faster.

Early Relapse Prevention

Relapse prevention at this stage means recognizing that you’re in emotional relapse and changing your behavior. Recognize that you’re isolating and remind yourself to ask for help. Recognize that you’re anxious and practice relaxation techniques. Recognize that your sleep and eating habits are slipping and practice self-care. 

If you don’t change your behavior at this stage and you live too long in the stage of emotional relapse you’ll become exhausted, and when you’re exhausted you will want to escape, which will move you into mental relapse. 

Practice self-care. The most important thing you can do to prevent relapse at this stage is take better care of yourself. Think about why you use. You use drugs or alcohol to escape, relax, or reward yourself. Therefore you relapse when you don’t take care of yourself and create situations that are mentally and emotionally draining that make you want to escape.

For example, if you don’t take care of yourself and eat poorly or have poor sleep habits, you’ll feel exhausted and want to escape. If you don’t let go of your resentments and fears through some form of relaxation, they will build to the point where you’ll feel uncomfortable in your own skin. If you don’t ask for help, you’ll feel isolated. If any of those situations continues for too long, you will begin to think about using. But if you practice self-care, you can avoid those feelings from growing and avoid relapse.  (Reference: www.AddictionsAndRecovery.org)

In mental relapse there’s a war going on in your mind. Part of you wants to use, but part of you doesn’t. In the early phase of mental relapse you’re just idly thinking about using. But in the later phase you’re definitely thinking about using.

The signs of mental relapse are:

• Thinking about people, places, and things you used with
• Glamorizing your past use
• Lying
• Hanging out with old using friends
• Fantasizing about using
• Thinking about relapsing
• Planning your relapse around other people’s schedules

It gets harder to make the right choices as the pull of addiction gets stronger.

Techniques for Dealing with Mental Urges

Play the tape through. When you think about using, the fantasy is that you’ll be able to control your use this time. You’ll just have one drink. But play the tape through. One drink usually leads to more drinks. You’ll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and you’ll get caught in the same vicious cycle. When you play that tape through to its logical conclusion, using doesn’t seem so appealing.

A common mental urge is that you can get away with using, because no one will know if you relapse. Perhaps your spouse is away for the weekend, or you’re away on a trip. That’s when your addiction will try to convince you that you don’t have a big problem, and that you’re really doing your recovery to please your spouse or your work. Play the tape through. Remind yourself of the negative consequences you’ve already suffered, and the potential consequences that lie around the corner if you relapse again. If you could control your use, you would have done it by now.

Tell someone that you’re having urges to use. Call a friend, a support, or someone in recovery. Share with them what you’re going through. The magic of sharing is that the minute you start to talk about what you’re thinking and feeling, your urges begin to disappear. They don’t seem quite as big and you don’t feel as alone.

Distract yourself. When you think about using, do something to occupy yourself. Call a friend. Go to a meeting. Get up and go for a walk. If you just sit there with your urge and don’t do anything, you’re giving your mental relapse room to grow.

Wait for 30 minutes. Most urges usually last for less than 15 to 30 minutes. When you’re in an urge, it feels like an eternity. But if you can keep yourself busy and do the things you’re supposed to do, it’ll quickly be gone.

Do your recovery one day at a time. Don’t think about whether you can stay abstinent forever. That’s a paralyzing thought. It’s overwhelming even for people who’ve been in recovery for a long time. 

One day at a time, means you should match your goals to your emotional strength. When you feel strong and you’re motivated to not use, then tell yourself that you won’t use for the next week or the next month. But when you’re struggling and having lots of urges, and those times will happen often, tell yourself that you won’t use for today or for the next 30 minutes. Do your recovery in bite-sized chunks and don’t sabotage yourself by thinking too far ahead.

Make relaxation part of your recovery.

Relaxation is an important part of relapse prevention, because when you’re tense you tend to do what’s familiar and wrong, instead of what’s new and right. When you’re tense you tend to repeat the same mistakes you made before. When you’re relaxed you are more open to change.  (Reference: www.AddictionsAndRecovery.org)

Physical Relapse

Once you start thinking about relapse, if you don’t use some of the techniques mentioned above, it doesn’t take long to go from there to physical relapse. Driving to your dealer. 

Driving to the liquor store.

It’s hard to stop the process of relapse at that point. That’s not where you should focus your efforts in recovery. That’s achieving abstinence through brute force. But it is not recovery. If you recognize the early warning signs of relapse, and understand the symptoms of post-acute withdrawal, you’ll be able to catch yourself before it’s too late.

MAT TEAM PLAN OF EDUCATION POLICIES

1. Program physicians and physician extenders operating under a plan of education shall be supervised by the medical director at a frequency appropriate for the qualifications and experience of an employee.
2. The program administrator shall document a plan of education, maintain all records regarding plans of education for professional medical staff; and ensure that the medical director monitors and certifies completion of each plan of education.
3. The medical director shall approve each plan of education and the ability of professional medical staff to work independently within his or her scope of practice.
4. The state opioid program oversight administrators may request documentation of continuing education during the probationary period and later if the documentation is not satisfactory.
5. Newly employed counselors and non-physician clinical and clerical staff working with the MAT program who are without experience in addiction or medication assisted treatment shall receive initial training of at least 20 hours and will include the following:
   1. Substance use disorder overview;
   2. Opioid treatment, detoxification protocols, recovery models and basic pharmacology and dosing; 
   3. Characteristics of the substance use disorder population;
   4. Toxicology screening and observation of sample collection;
   5. Program policies and procedures;
   6. Confrontation, de-escalation and anger management;
   7. Cultural sensitivity as needed and appropriate;
   8. Current strategies for identifying and treating alcohol, cocaine and other substance use disorders;
   9. Identification of co-occurring behavioral health or developmental disorders;
   10. Other clinical issues as appropriate for the population served.

MAT TEAM QUALIFICATIONS & CONTINUING EDUCATION POLICY

The program Medical Director shall ensure that all physicians, physician assistants, advanced practice registered nurses, registered nurses, licensed practical nurses, counselors, psychologists, marriage and family therapists, social workers and other licensed or certified professional care providers comply with the credentialing requirements of their respective professions, obtain and maintain a current license and / or certification, and complete all continuing education requirements of their respective licensing board.

Clinical staff of the OBMAT program may include employees, independent contractors or both. The OBMAT program Medical Director shall be responsible for ensuring that staff and contractors comply with all provisions of the continuing education policy. All clinical staff members and volunteers shall complete initial and continuing education and training that is specific to their job.

Suboxone/Vivitrol Provider and BH Provider

Communication between behavioral providers and your Suboxone/Vivitrol Prescribing Physician other Behavioral health providers and/or facilities is important to ensure that you receive comprehensive and quality health care. This form will allow your behavioral health provider to share protected health information (PHI) with your other provider. This information will not be released without your signed authorization. This PHI may include diagnosis, treatment plan, progress, and medication, if necessary.

Patient Rights 

•  You may end this authorization (permission to use or disclose information) any time by contacting the practitioner’s office. 
• If you make a request to end this authorization, it will not include information that may have already been used or disclosed based on your previous permission. For more information about this and other rights, please see the applicable Notice of Privacy Practices.
• You have a right to a copy of this signed authorization. 

Patient Authorization

I hereby authorize the name(s) or entities written below to release verbally or in writing information regarding any medical, mental health and/or alcohol/drug abuse diagnosis or treatment recommended or rendered to the following identified patient. I understand that these records are protected by Federal and state laws governing the confidentiality of mental health and substance abuse records, and cannot be disclosed without my consent unless otherwise provided in the regulations. I also understand that I may revoke this consent at any time and must do so in writing. This consent expires in one year (12) months from the date of my signature below unless otherwise stated herein. 

__________________________________________(BH Provider) authorized to release protected health information related to the evaluation and treatment of 

_________________________________ to (Suboxone/Vivitrol Prescribing Physician)

(Member Name) ______________________________________________

(Medicaid ID#) _______________________________________________

(Date of Birth – MM/DD/YYYY) __________________________________

Suboxone or Vitriol Prescribing Physician: __________________________________________

Physician Phone: _____________________________________________________________

Physician Address: ____________________________________________________________

BH Provider Name: ____________________________________________________________

BH Provider Phone: ____________________________________________________________

BH Provider Address: __________________________________________________________

Prescription Drugs Prohibited While part of the Medication Assisted Treatment Program

(Plus derivatives from these medication)

Depressants/Benzodiazepines Narcotics – Opiates

Muscle Relaxers

Barbituates Stimulants

*NOTE: This list is not all inclusive. Any mind or mood-altering chemical is forbidden. If you wonder, better ask!