Compliance Attestation Form | CompreCare | Rx Specialty Pharmacy

Compliance Attestation Form

  • Patient Safety and Anti-Diversion Affidavit - Buprenorphine
    Completed by prescribing provider for:

    As a DEA-waivered prescriber of buprenorphine, I, the undersigned prescribing provider recognize that I have an affirmative obligation to take steps to prevent unlawful use of buprenorphine-based medications, namely buprenorphine without naloxone (Subutex and its generic equivalents). This includes identifying and preventing all behaviors not indicated for such medications, including diversion, loaning, borrowing, renting, reselling, abusing, or any other utilization of such medications not indicated and accepted by the DEA and FDA, and/or any use whatsoever by anyone other than the patient to whom it is prescribed.

    Subutex and similar advisory: Patients receiving treatment for Opioid Use Disorder are prone to diverting and misusing medications. There are serious risks, including death, associated with misuse/abuse of Subutex, particularly when used at the same time as benzodiazepines or other drugs that depress the central nervous system. Certain “red flags” indicative of possible diversion, and/or the presence of drugs of abuse in a tested sample of a patient who has been prescribed Subutex, have implications for CompreCare’s ability to safely fill and dispense the medication to the patient, and for your on-going treatment.

    I understand that it is CompreCare’s position that prescribing Subutex requires increased structure and collaboration between the prescribing provider and our pharmacy for safe treatment, and prevention of diversion and abuse. In an effort to help meet shared obligations for safe prescribing and dispensing, CompreCare I am submitting this affidavit. I understand that this affidavit should accompany every new patient for Subutex that is sent to CompreCare by me or my office staff. I understand that CompreCare may ask me to produce results of recent toxicology screens of patients with prescriptions for Subutex as required/advised by federal and state law. Additionally, I understand that CompreCare may ask me to update the information contained on this affidavit from time-to-time in writing or via telephone consult, and the information that I, or my office staff provide, will be documented in the patient’s record at CompreCare.

    Buprenorphine-naloxone combination medications advisory: I understand that buprenorphine-naloxone combination medications such as Suboxone, Bunavail, and Zubsolv, and similar medications or generics, are widely considered safer, more effective, and less prone to diversion when compared to Subutex. Where clinically indicated and whenever possible, CompreCare recommends that prescribing providers consider prescribing such medications and discuss the risks and benefits of doing so in place of Subutex or similar buprenorphine medications that do not contain naloxone.

    CompreCare recognizes that certain patients experience adverse side effects related to use of buprenorphine-naloxone combination, have previously become stable using Subutex, and/or cannot afford safer alternatives. In such instances, CompreCare does not recommend changing the regimen or treatment that is safe, effective, and otherwise clinically indicated, but may require further information to support continuing treatment with Subutex.

  • I affirm that I am prescribing buprenorphine as part of an appropriate individualized treatment plan for the patient indicated in this affidavit. I further confirm that I am not exceeding the patient limits under by DEA waiver to prescribe buprenorphine, nor violating state or federal regulations in any other way. I understand that CompreCare reserves the right to refuse any prescription that, in its sole discretion, does not meet customary best practices for treatment of Opioid Use Disorder via Medication-Assisted Treatment, and/or is suspected for diversion or misuse.

    General Assessment: (Y=Yes, N=No, N/A=Not Applicable; for patient treatment informational purposes; absolute indications not necessarily required for dispensing, but may require further consultation between pharmacy and provider, and/or supporting documentation; please attach any supporting treatment plan documentation or notes that may be required to further explain any answer)

  • If prescribing buprenorphine without naloxone (Subutex and generic): (please provide explanation or supporting records).

  • Presence of “Red Flag” Behaviors:

  • Prevention:

  • Date Format: MM slash DD slash YYYY