1. Purpose of buprenorphine or injectable/oral naltrexone.

 The purpose of this treatment is to support the patient in managing symptoms of opioid use disorder (OUD). 

Buprenorphine is a partial opioid agonist and is prescribed to reduce cravings and withdrawal symptoms, aiding the patient in achieving stability and recovery. Buprenorphine treatment is part of a comprehensive program provided by MATClinic Physicians Practice Group, LLC, which includes clinical monitoring and support.

Oral and injectable naltrexone (Vivitrol©) is approved for the treatment opioid use disorder (OUD) primarily by blocking the effects of opioids (eg oxycodone, heroin, fentanyl). It functions as an opioid antagonist, which means it blocks opioid receptors in the brain. This action helps to reduce cravings and the pleasurable effects associated with opioid use, thereby supporting abstinence and decreasing the likelihood of relapse. Naltrexone is taken orally or administered via a monthly injection (known as Vivitrol©). Its use is often most effective as part of a comprehensive treatment program provided by MATClinic Physicians Practice Group, LLC, that includes monitoring and support.

2. Explanation of buprenorphine, naltrexone, and treatment process.

Buprenorphine and naltrexone (Vivitrol©) are medications approved by the FDA for the treatment of opioid use disorder. 

Buprenorphine works by partially activating opioid receptors in the brain, which helps reduce cravings and withdrawal symptoms. Naltrexone, on the other hand, is an opioid antagonist that blocks the effects of opioids at their receptor sites, preventing relapse and reducing cravings.

The minor will be supervised by qualified medical professionals at MATClinic Physicians Practice Group, LLC, who specialize in addiction medicine and will receive ongoing support.

This treatment plan also includes individual and family therapy and counseling sessions provided by partner counseling programs tailored to support the patient’s overall recovery and well-being.

3. Benefits of buprenorphine and naltrexone treatment.

•  Reduced cravings and withdrawal symptoms, supporting patient stability.

•  Lower risk of relapse and overdose when compared to untreated opioid use disorder.

•  Improvement in overall functioning and quality of life with consistent treatment.

4. Potential Risks and Side Effects

While both buprenorphine and naltrexone are generally well-tolerated, they can cause specific side effects:

• Buprenorphine:

• Drowsiness, dizziness, or lightheadedness

• Nausea, vomiting, or constipation

• Possible development of physical dependence or withdrawal symptoms if the medication is stopped abruptly

• Risk of misuse if not taken as prescribed

• Naltrexone: 

• Headaches, muscle cramps, or irritability

• Nausea or vomiting

• Rarely, severe reactions (cellulitis, abscess, soft tissue necrosis) at the injection site for injectable naltrexone (Vivitrol©), the injectable form of naltrexone

• Monitoring and Patient Instructions: MATClinic Physicians Practice Group, LLC will monitor the patient closely to minimize these risks. It is essential that the minor follow all instructions regarding dosage and medication use to ensure safety and effectiveness.

5. Consent for Treatment

By signing this form, I understand and agree to the following:

• I give permission for MATClinic Physicians Practice Group, LLC to prescribe buprenorphine or naltrexone to my child or ward, under the supervision of a licensed healthcare provider.

•  I understand the purpose, benefits, and potential risks associated with buprenorphine or naltrexone treatment, as well as the importance of adhering to all prescribed treatment protocols.  

• I understand that my child or ward's information will be kept confidential in compliance with applicable state and federal privacy laws, including HIPAA.

6. Consent for Ongoing Communication and Updates

I consent to ongoing communication with MATClinic Physicians Practice Group, LLC as necessary to support my child or ward's treatment and ensure safety. I understand that updates may be provided in person, by phone, or in writing as appropriate.

I agree to sign a release of information for my child's pediatrician for collaboration of care and record exchange purposes. 

I agree to sign a release of information for my child's counselor, therapist and/or psychiatric practitioner for collaboration of care and record exchange purposes.

I, in conjunction with Minor Client, have fully and accurately disclosed Minor Client’s medical history to MATClinics, and understand that Minor Client must be under the care of a primary care provider, general practitioner or pediatrician. I am aware of the significant or common risks, benefits, side effects and adverse reactions that can be associated with the Treatment(s) as applied to a minor, and I have had full opportunity to ask any questions of MATClinics related to the Treatment(s).  I agree that Minor Client will be under the care of another medical provider for all other conditions not directly related to the Treatment(s).  I understand that MATClinics can work in conjunction with, but cannot replace, Minor Client’s regular primary care physicians, such as general practitioners or pediatricians, or any specialist providers involved in the care of Minor Client.  I understand and acknowledge that neither MATClinics nor associated staff shall be liable for any injury or damages Minor Client suffers as a result of my failure to fully and accurately disclose Minor Client’s medical history to MATClinics prior to Treatment(s), or to update such history in a timely manner throughout the Treatment(s).

I agree to immediately report any medical problems Minor Client experiences during or following the Treatment(s), including any unusual symptoms (whether or not such symptoms are described in the informed consent disclosure documents I received), to MATClinics.  I hereby release MATClinics and its staff from liability from any damages or injuries Minor Client suffers as a result of my failure or Minor Client’s failure to follow MATClinics' instructions or the terms of this Consent.  In the event Minor Client, while under my care, experiences an emergency medical situation, including, without limitation, an allergic reaction, I will seek medical help for Minor Client at an emergency room.  I understand that, generally, MATClinics is not equipped to render emergency medical assistance.  I further understand, however, that should an emergency situation arise concerning the care of Minor Client while Minor Client is on-premises at MATClinics, and in the event I am not immediately present to consent to emergency treatment of Minor Client during the emergency situation, and in the event a MATClinics provider determines that there is substantial risk of death or immediate and serious harm to Minor Client and that the life or health of Minor Client would be affected adversely by delaying treatment in order to obtain my consent, MATClinics, and any of its physicians or qualified staff, may treat Minor Client, or arrange for treatment of Minor Client by a qualified emergency services provider, without my consent. 

 I understand that neither MATClinics nor its staff guarantees that Minor Client will experience particular results as a result of the Treatment(s).  MATClinics staff have explained the costs of the Treatment(s) to me, and I agree to pay those costs according to agreed-upon terms. 

 I understand that if there are any changes in Minor Client’s medical history or there are any changes in Minor Client’s medications or any other changes relevant to the Treatment(s), I will promptly advise MATClinics. I understand MATClinics will discuss all major risks and complications that may be associated with the treatment(s) but that it is not reasonable to expect MATClinics to explain all possible risks and complications of the Treatment(s). I understand that risks, complications, and undesired results are not necessarily the results of errors of judgment by MATClinics or associated staff. Moreover, I understand that material changes to Minor Client’s physical condition or health, or Minor Client’s reaction to the Treatment(s), may warrant changes in the administration of the Treatment(s), and MATClinics will explain the need for those changes and available options at that time.

 I have explained to Minor Client that MATClinics, or associated staff involved in care of Minor Client, may communicate directly with me regarding treatment (including, without limitation, Treatment(s)) needed by or provided to Minor Client, even if Minor Client expressly objects to such communication.

 I have read this Consent (or have had it read to me) and have also had an opportunity to ask questions about the Consent and understand to my satisfaction the care and Treatment(s) Minor Client may receive. My signature below acknowledges my consent to the examination, evaluation and proposed course of care and Treatment(s) at MATClinics, as provided to Minor Client.

 I understand that, in the event Minor Client reaches the age of majority, or otherwise qualifies to independently consent to medical treatment pursuant to Maryland law, this Consent will terminate, and MATClinics will require Minor Client to independently consent to further care or Treatment(s). I understand that at that time, Minor Client will also need to complete additional HIPPA release forms, at their discretion, if I wish to continue to communicate with the treatment team about Minor Client.