Pain Management Controlled Substances Contract
The purpose of this agreement is to create an understanding regarding controlled substances (a type of medication that is regulated by states and the Federal government) that may benefit your pain symptoms. My goal is to treat you as safely with these potent medications and also prevent abuse of or addiction to these medications. Medications such as opioids (narcotic analgesics), benzodiazepine tranquilizers, barbiturate sedatives, and muscle relaxants such as Soma (carisoprodol), that may be useful in managing pain, can be problematic in several ways. These medications have “street value” and potential for abuse. Although these medications may be prescribed with the goal of improving your comfort and functionality, their medical use is also associated with the risk of serious adverse effects such as development of an addiction disorder or a relapse in a person with a prior addiction history. The extent of this risk is uncertain, but it is known to be higher in certain vulnerable patients. My goal is to have you take the lowest possible dose of medication that is reasonably effective in managing your pain and improving your function and when possible have it tapered and eventually discontinued while at the same time monitoring and managing these potential risks.
Because these medications have the potential for abuse or diversion (i.e. sharing, trading, or selling to ANYONE other then whose name is on the prescription), strict accountability is necessary for both medical safety and legal reasons. Therefore, the following policies are agreed to by you, the patient, to help me keep you safe and to provide you with good care.
1. This contract is based on post operative pain management for the first three months post op. Pain requiring narcotics beyond three months will result in a referral to Pain Management Specialist. If a pain specialist can not be established, progressive reduction of pain medications will occur with each refill until tapered off completely.
2. You must get a prescription for all controlled substances from the physician whose name appears below or, during his or her absence, by the covering physician, unless specific written authorization is obtained for an exception. (Multiple sources can lead to untoward medication interactions or poor coordination of treatment.)
3. You must obtain all controlled substances from the same pharmacy. Should the need arise to change pharmacies, our office must be informed.
4. You must inform our office of any new medications or medical conditions and of any adverse effects you experience from any of the mediations that you take.
5. You must give the prescribing physician permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability and coordinating your care.
6. You may not share, sell or otherwise permit others to have access to these medications. You must take all mediations exactly as prescribed, unless you develop side effects. If you develop side effects, you must consult with your doctor or local emergency providers.
7. You must not stop these medications abruptly or without consulting the prescribing physician as an abstinence/withdrawal syndrome may develop.
8. You must agree that your urine may be tested for controlled substances before initiation of therapy and that random urine follow up testing may be done. You must cooperate in such testing, and you must agree that the presence unauthorized substances, illicit substances or absence of prescribed medications may prompt referral for assessment for addictive disorder and possible tapering and discontinuation of the controlled substances immediately or in the future.
9. You will not give your prescriptions or bottles of these medications to anyone else. These substances may be sought by other individuals with chemical dependency and should be closely safeguarded. You will take the highest degree of care with your medications and prescriptions. You will not leave them where others might see or otherwise have access to them.
10. You must bring original containers of medication to each office visit.
11. You must keep all controlled substances in a secure area. Since the medications may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of such people.
12. You must exercise extreme caution when taking these medications and driving or operating heavy machinery. The use of these medications may induce drowsiness or change your mental abilities, thereby making it unsafe to drive or operate heavy machinery. The effects of these medications are particularly problematic during any dose changes. If you are the slightest bit impaired, you must refrain from these activities.
13. You must discuss the long term use of controlled substances with you physician. Prolonged opiod use can be associated with serious health risks. You need to understand these risks.
14. You must agree that mediations will not be replaced if they are lost, flushed down the toilet, destroyed, left on an airplane etc. If your medication has been stolen and you complete a police report regarding the theft and present that report the prescribing physician, an exception may be made at the discretion of your treating physician.
15. You must agree that easy refills will not be given.
16. You understand that prescriptions may be issued early only if the physician or patient will be out of town when a refill is due. These prescriptions will contain instructions to the pharmacists that they are not to be filled prior to the appropriate date.
17. You agree that if the responsible legal authorities have questions concerning your treatment, as might occur, for example if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our records of controlled substances administration.
18. You agree that failure to adhere to these polices may result in tapering and cessation of therapy with controlled substance prescribing by these physician or referral for further specialty assessment.
19. You agree that prescription renewals are contingent on keeping scheduled appointments. Do not phone for prescriptions after hours or on weekends. If you receive any controlled substances in the ER, you must report that incident to your prescriber, in writing within 48 hours.
20. You recognize that any medical treatment is a trial and that continued prescription is contingent on evidence of benefit and improved functionality.
21. You acknowledge that the risks and potential benefits of therapy with controlled substances have been explained to you and that you have had the opportunity to ask any questions that you may have.
22. You understand and agree that failure to adhere to these policies will be considered noncompliance and many result in cessation of opioid prescribing by your physician and possible dismissal from this clinic.
23. You affirm that you have full right and power to sing and be bound by this agreement. You further affirm that you have been given the opportunity to ask any questions you may have and that you have read, understand, and accept all of its terms.