• Patient Agreement for Treatment with Controlled Substances / Opioids

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  • Your healthcare team has decided to manage your  acute and/or chronic medical problems. Sometimes it is necessary as a part of your treatment plan to dispense you. All controlled substances posse the risk for abuse and addiction. We advise you to minimize use of controlled substances. Never associate with recreational drugs or alcohol which can increase the risk of sudden death. Dispensing and sharing your own controlled medications is illegal and is punishable by law under the drug trafficking law and rule. 


    I am agreeing to following rules regarding management of my medical conditions with use of controlled medications:


    1. I will take my medications as prescribed

    2. I will not take more than what I am prescribed

    3. I will not share any medications with others

    4. I will refrain from any alcohol and other legal and illegal substances

    5. I will inform my other providers of all controlled medications

    6. I will not come early for refills, if I do, I understand this request will be denied. 

    7. I will consent to monthly drug screens and understand if not paid my insurance it is my responsibility

    8. I understand my drug screen should reflect the medications prescribed medications. If not my refill will be denied

    9. I understand that if I am positive for medications not prescribed my refill will be denied

    10. I understand that I am required to use the same pharmacy for safety purposes.  I will obtain my controlled substances prescriptions only from                                                    

    and use only .

    11. I understand that use of controlled substances are not guaranteed and my provider can offer alternative treatments plans which does not require controlled medications

    12. I understand that the goal is to wean to minimal dosing to control disease processes and minimize the risks of overdose and other declines in conditions up to and including death

    13. I will fill my narcan order if prescribed to prevent death associated with accidental and non-accidental overdose

    14. I understand that if I lose any medications that are controlled by the DEA those medications will NOT be filled early

    15. I will inform my provider with ANY signs of addiction such as doctor shopping, buying drugs illegally, multiple ED visits and inappropriate drug screens

    16. I understand if I am sent to pain management I must comply with their recommendations

    17. I understand if I am sent to psychiatry for evaluation I must comply with their recommendations. I also understand I must be on a longacting medication to treat anxiety if I am on a short acting medication

    18.  I do not have current problems with substance abuse or dependence (addiction).

    19.  I am not currently involved in the sale, diversion, illegal possession, or transport of controlled

    substances, which include the following: opioids ("narcotics"), sleeping pills, anxiety

    ("nerve"), pills, and/or painkillers.

    20.  I understand that this treatment option will be discontinued if any of the following occur:

    a.  If my healthcare providers believe that opioids have not been effective in helping to

    manage my pain

    b.  If I give away, sell, or misuse the medication

    c.  If I am using illegal substances or abusing alcohol

    d.  If medication-related side effects become intolerable

    e.  If I obtain opioids from any unapproved source

    f.   If other, more effective, treatments become available

    g.  If I am unable to manage my pain medication according to this agreement

    21.  If my healthcare providers choose to discontinue my opioid treatment, they will manage the

    dose to avoid withdrawal symptoms.  If providers believe I have a drug dependence

    problem, they may refer me elsewhere for management of that condition

    22. I understand that if I am in a suboxone, buprenorphine or methadone treatment clinic, I CANNOT obtain any controlled substances at Med-Care Group 

    23. I understand that I seek treatments from other providers outside of referrals such as pain management and/or psychiatry,  I will be denied refills from Med-Care Group

    24. I will notify Med-Care Group of any surgeries or procedures in which another may prescribed a short term treatment of additional controlled medications. I will bring in copies of the medical record indicating the treatment plan.  

    25. I understand that I will periodically need diagnostic testing which can include but is NOT limited to blood work, 

    EKG, spirometry and drug screens. Failure to consent will result in no refills for any controlled medications. 

    26. Although marijuana is legal in some states for recreational use and some for medical use; it is our office policy that if you use marijuana on a daily basis you will be referred to another provider for controlled substances. We will still treat your medical problems with alternative treatment plans that exclude controlled substances. 


    Opioid medications. 

     The goal of this treatment is to improve your quality of life, your functional ability (including social and work activities), and your pain level.  This form of treatment has risks and potential side effects, including the following:


    Opioid side effects: Please note this list is not all inclusive

    1. Sedation

    2. Constipation

    3. Nausea and vomiting

    4. Confusion or change in thinking ability

    5. Difficulty with balance, which may make it unsafe to operate heavy equipment or motor

    vehicles

    6. Sleepiness and drowsiness

    7. Decreased respiration or breathing

    8. Physical dependence, which means if you abruptly stop taking this medication you may experience withdrawal.  Symptoms of withdrawal include: restlessness, sweating, diarrhea, abdominal cramping, "goose flesh," and anxiety.

    9. Psychological dependence or addiction

    10. Tolerance, which means that you may need more medication to get the same effect

    11. Risk regarding pregnancy: Children born to mothers on opioids will likely be physically dependent on the drug at birth

    12. Death


    Benzodiazepines side effects: please note this list is NOT all inclusive of potential side effects


    1. Drowsiness, sedation

    2. Hypotension 

    3. Dizziness 

    4. Unsteadiness  

    5. Hallucinations 

    6. Depression

    7. Coma

    8. Respiratory failure

    9. Constipation

    10. Addiction

    11. Extrapyramidal reactions

    12. Memory impairments or loss

    13. Speech difficulties

    14. Suicidal ideations

    15. Withdrawal symptoms

    16. Changes in libido, impotence

    17. Death

    18. Changes in liver function and enzymes


    Stimulant side effects: Please note this list is NOT all inclusive of potential side effects

    1. Hypertension

    2. Tachycardia

    3. Palpitations

    4. Agitation

    5. Jitteriness

    6. Euphoria

    7. Aggressive behaviors

    8. Diaphoresis

    9. Appetite changes

    10. Addiction

    11. Weight loss

    12. Diarrhea, nausea or vomiting

    13. Impotence

    14. Death


    The mixing of benzodiazepines with opiates is EXTREMELY dangerous and can result in DEATH. 

    The following is NOT an inclusive list of potential side effects:

    1. Death

    2. Respiratory depression

    3. Slurred speech

    4. Overdose

    5. Addiction


    I have read this document, understand it, and have had all questions answered satisfactorily.  I consent to the use of controlled substance/ opioids to help control my pain and understand that this treatment will be conducted in accordance with the conditions stated above.

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