Your healthcare provider (doctor) has recommended you take a controlled substance (opioid, benzodiazepine, amphetamine, attention deficit disorder medication, sedative hypnotic) as part of your treatment plan for pain, anxiety, sleep, or attention deficit disorder. These medications have the potential for dependency, addiction, overdose, or withdrawal. 

 

This agreement, which includes the attached Controlled Substance Educational Document, helps you know important information about the controlled substance you are taking, including safe and legal use, risks, your responsibilities while taking the medication, and your healthcare provider’s responsibility to provide you safe medication management. 

 

 

AGREEMENT: 

I WILL ABIDE BY THE FOLLOWING TERMS AND REQUIREMENTS OF THIS AGREEMENT: 

 

·         Use this medication exactly as prescribed (I will talk to my healthcare provider if I want to make any changes) 

·         Not share this medication with anyone and keep it in a safe place where no one other than me can get it. 

·         Obtain this medication only through a prescription written by my healthcare provider. 

·         Notify my healthcare provider within 2-3 days if I am prescribed, or currently taking, other controlled substances from other providers (including medical marijuana) 

·         Come to all my scheduled appointments, and at least once every six months. To keep me safe and healthy, I might need to be seen in the office more frequently while taking these medications. 

·         Bring my medication in for my healthcare provider to do a pill count, if requested at any time 

·         Submit a urine specimen for drug testing prior to prescribing (opioid/benzodiazepine) and randomly when my Healthcare provider requests it. 

·         Request refills only during my office visits or during regular business hours (not during evenings or weekends). It may take up to 3 days to refill my prescription. My prescription will be electronically prescribed to my single, designated pharmacy (if they do not accept electronic prescriptions, I may pick up at my healthcare providers office). The prescription will not be refilled early. 

·         Inform my healthcare provider if I have had dependency or addiction issues or if I am taking a prescription for treatment of substance abuse. 

·         Inform my healthcare provider if my medication is lost or stolen and provide a copy of a police report 

·         Appropriately dispose of any controlled substances that I am no longer taking. 

·         Tell my healthcare provider if I am pregnant. 

·         Inform my healthcare provider if I feel I am becoming dependent or addicted to this medication. 

·         Avoid using or possessing illegal substances, misusing prescribed medication, or misusing alcohol. 

·         I understand if my provider feels I am at risk of opioid overdose or toxicity, they may prescribe Narcan for me 

·         Know that in most states driving while taking this medication may be considered driving under the influence (DUI) 

·         I will always treat my Healthcare Provider, and all office staff with respect at all times, just as I expect to be treated by them. If m y conduct is deemed inappropriate (disruptive or abusive), I understand that my provider may choose to no longer prescribe this medication for me, or I may be dismissed from the medical group. 

 

SIGNATURE: 

My signature below acknowledges that:  

 

·         I have read, understand, and agree to all statements set forth above in this agreement, including the attached Controlled Substance Educational Document as reviewed with me by my healthcare provider or clinical staff representative.  

·         I am bound to the terms and requirements of this agreement and the attached Controlled Substance Educational Document  

·         I was provided sufficient time to review this agreement and the attached Controlled Substance Educational Document, had the opportunity to ask questions, and those questions were answered to my satisfaction.  

·         I understand that my provider will determine the optimal dose, which is dependent on many factors, including: symptom control, ability to function, potential for dependency/addiction, side effects, and adherence to this agreement.  

·         I have been made aware of the risks of addiction and overdose associated with controlled substances; the increased risk of addiction if I suffer from mental or substance use disorder; the dangers of taking a controlled substance containing an opioid with benzodiazepines, alcohol or other central nervous system depressants, available non-opioid treatment options, and any other information deemed appropriate under 21 CFR 201.57(c)(18) (relating to specific requirements on content and format of labeling for human prescription drug and biological products described in 201.56(b)(1))  

·         I understand that if I do not sign this agreement or follow the terms of this agreement, my healthcare provider may stop prescribing the medication (taper over several days), and I would no longer be eligible to receive any controlled substances. However, my provider may continue to manage my acute and chronic illnesses. I may be referred to another healthcare provider to assist with my condition or I may be dismissed from the practice (no longer be my healthcare provider)  

·         I received the educational document that includes additional information regarding controlled substances (opioids, benzodiazepines, amphetamines, attention deficit disorder medications, sedative hypnotics)  

·         I consent to the prescription of a controlled substance.