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.
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
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
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
Benzodiazepines side effects: please note this list is NOT all inclusive of potential side effects
1. Drowsiness, sedation
8. Respiratory failure
11. Extrapyramidal reactions
12. Memory impairments or loss
13. Speech difficulties
14. Suicidal ideations
15. Withdrawal symptoms
16. Changes in libido, impotence
18. Changes in liver function and enzymes
Stimulant side effects: Please note this list is NOT all inclusive of potential side effects
7. Aggressive behaviors
9. Appetite changes
11. Weight loss
12. Diarrhea, nausea or vomiting
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:
2. Respiratory depression
3. Slurred speech
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.