EMERGENCY TAKE-HOME- COVID-19
Take Home Medication-Person Served Responsibility Statement
Take Home Methadone is a privilege.
Regardless of your drug use status, employment status, or any special situations, the staff of CTR will make sole determination regarding take home status based upon state and federal regulation interpretation.
2.Methadone is Deadly to Children.
Extremely low doses (less than 5mg.) can be enough to kill a child. You will be held legally responsible for this prescribed take home medication in the event you do not properly stored.
3.Methadone can be Deadly to Adults.
Methadone taken by someone other than you can result in a fatal drug overdose. Methadone doses can be fatal in adults as well as children. You will be held legally responsible for the prescribed take home medication in the event you do not properly store it
4.Diversion of Methadone is a Crime.
The sale of methadone can lead to criminal prosecution.
If a take-home bottle is lost or stolen you must report it to the police in the town/city where this occurred. Bring documentation to the clinic.
All Take-Home Bottles MUST be returned the day you return to the Clinic. Failure to do so may result in not being medicated until the bottle(s) is (are) returned. Bottles must be intact and label must be legible. Defaced/lost medication labels may lead to loss of take home status.
Unexcused Absences After a Take-Home.
Missing a day after a take-home, without verifiable reasons for absence, may result in a loss of all take home privileges and future emergency take-home medication.
All take-home bottles are required to be kept in a locked box approved for use by the clinic. It is your responsibility to store the bottle(s), in the locked box, out of the reach of children and safe from the risk of theft. All medication is dispensed in a child-proof container by CTR.
6.All prescription medications must be brought to the Nursing Department before being taken. If the medication is not brought in and a urinalysis comes back positive the Program Physician/Medical Director reserves the right to suspend or revoke take-home privileges. Take home medication may be suspended while taking prescription opiates.
If any problems or issues arise out of my receiving emergency take-homes, I understand that that I may not receive emergency take-home medication in the future. I also understand staff may be contacting me periodically to ensure there are no issues associated with my take-homes and it is my responsibility to answer or return all phone calls.
The information on this sheet has been explained to me, I have had the opportunity to ask any questions and have received a copy of this document in the Person Served Handbook.
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Person Served Sig./Date Staff Signature/Date