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A Community Reinforcement Approach: Treating Cocaine Addiction



Exhibit 32: Backup Disulfiram Contract

It has been shown that alcohol abstinence aids in remaining cocaine abstinent. Disulfiram is an effective aid in achieving alcohol abstinence. By choosing to take disulfiram, I make a choice not to drink.

With that in mind, I,______________________________, agree that if I provide a positive urine sample for cocaine, fail to provide a scheduled sample, or drink to intoxication, I will start disulfiram therapy.

If any of the above occur, I agree to take disulfiram for _______ days. I will follow the procedures for taking disulfiram observed at the clinic and on my own on nonclinic days, and I will comply with blood work as required.

In order to be cleared by a physician to take disulfiram, I will make an appointment with the designated staff for a medical update, and I will complete the laboratory work, if needed, as soon as possible.

 

Patient Signature:

________________________________

Therapist's Signature:

________________________________

Date:

________

 

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