Printable form/checklist

Description: 
A reference tool used to provide clinicians with stabilization resources for substance use disorder within active duty and veteran populations, including resources on pharmacological treatment and substance titration.
Source: 
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
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Description: 
The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater.
Source: 
Reprinted from Handelsman, L., Cochrane, K. J., Aronson, M. J., et al. (1987) Two new rating scales for opiate withdrawal. American Journal of Drug and Alcohol Abuse, 13 (3), 293–308. By courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Description: 
The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely).
Source: 
Reprinted from Handelsman et al. 1987, p. 296, by courtesy of Marcel Dekker, Inc.
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Patient Handouts: 
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Description: 
Provides a downloadable patient satisfaction form. The survey assesses satisfaction with the health center and staff.
Source: 
SAMHSA
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Description: 
This SAMHSA guideline provides information on buprenorphine treatment for nurses and other clinical support staff who assist with buprenorphine induction and maintenance.
Source: 
SAMHSA
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Physician stage in practice: 
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Pharmacy Consent Form for Buprenorphine Treatment

Description: 
By signing this Appointed Pharmacy Consent Form, the patient authorizes a provider to disclose to the pharmacy that he or she is being treated for opioid dependence; the pharmacy is also authorized to contact the provider to discuss treatment.

Name/Practice Name: ____________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, ZIP: ________________________________________
Phone: _______________________________________________
Fax: _________________________________________________

APPOINTED PHARMACY CONSENT

I, ______________________________________________[Patient Name- Print], do hereby:

(MD check all that apply)

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