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This survey is designed to collect information from providers about their patients who have had trouble filling a prescription for buprenorphine (Subutex) or buprenorphine/naloxone (Suboxone) here in NM.

Its goals are to provide data to pharmacy partners and other stakeholders and to help ensure people who are prescribed buprenorphine are able to get it when they need it. 

Information provided in this survey is being collected by the New Mexico Department of Health to supplement data on the number of buprenorphine prescriptions which are filled successfully: information that may be obtained from the NM Board of Pharmacy's Prescription Monitoring Program.

Please complete the following questions once for each patient you know was unable to fill a prescription. This survey will remain open for 8 weeks to track any changes in Rx availability from the beginnings of months through the ends of months.

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* 1. On what day did your patient try to fill their prescription?

Date

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* 2. What kind of pharmacy did you/ your patient try?

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* 3. What is the pharmacy's location? (city, town, hospital/clinic, or ABQ cross-streets)

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* 4. Was the prescription for ...

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* 5. Quantity & days' supply that you prescribed?

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* 6. Patient Alias (can be reverse initials, a nickname, anything short that you will associate with this patient, but not easily identifiable to others).

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* 7. Patient or chart number [optional, note that this SM account is HIPAA-compliant]

If your patient experiences problems on multiple days or with multiple pharmacies, please complete this form for each encounter.

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* 8. Is there anything else important to note about this patient & their problems filling their Rx?

Prescriber information is requested so that we can confirm provider status. NMDOH staff may email you to follow up regarding any comments or questions you share.

Individual prescriber names will not be included in summaries of the results. Results will be shared via email with every prescriber who participates.

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* 9. Prescriber's name and  clinic/location

Thank you very much for sharing this information.

If you have another patient encounter to report, after you click "Done" your answers will be saved and you'll be guided through the same set of questions.

If you don't have any more patient encounters to report, after clicking "Done," you can select "Exit" at the upper right and close the survey window. 

If you have any issues with the survey, please contact kathryn.lowerre@state.nm.us.

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