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MOUD Appendix

Appendix Resources

The following appendix resources provide sample protocols, clinical tools, assessment forms, and practice templates to support MOUD implementation.

Buprenorphine Induction

  • Appendix 4-1: Home Induction Clinic Protocol
  • Appendix 4-2: Patient Guide to Starting Buprenorphine at Home

Screening and Assessment Tools

  • Appendix 5-1: Drug Abuse Screening Test (DAST-10)
  • Appendix 5-2: Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool (TAPS)
  • Appendix 5-3: DSM-5 Criteria for Opioid Use Disorder
  • Appendix 5-4: Subjective Opiate Withdrawal Scale (SOWS)
  • Appendix 5-5: Clinical Opiate Withdrawal Scale (COWS)

Policies and Practice Templates

  • Appendix 8-1: Sample Buprenorphine Policy
  • Appendix 8-2: Sample Diversion Policy
  • Appendix 8-3: Documentation Template
  • Appendix 8-4: Sample Treatment Agreement
  • Appendix 8-5: Sample Patient Consent Form
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    • Home
    • Programs
      • ECHO Idaho
      • Southwest Idaho AHEC Continuing Education
      • Idaho Pediatric Psychiatry Access Line Action Center
    • Learning Activities
    • Activity Calendar
    • About
      • Accreditation
      • Partner With Us
      • Help Center
      • Contact Us