I authorize and direct my Provider and/or assistant(s) of his/her choice to prescribe controlled substances (CS):
Like all medications, CS have potential for both benefit and harm. The purpose of this document is to outline the potential benefits and harms so you can determine if the prescribed medication is suitable for you at this time.
Possible Benefits: Minimized pain, improved mobility and movement
Possible Risks/Side Effects: Addiction, physical dependence, and teolerance
Possible Side Effects: Constipation (common & persistent), nausea and vomiting (usually only in first few days), reduced production of testosterone (may cause reduced libido and fertility in men), reduced production of estrogen & progesterone (may cause periods to stop, reduced libido & fertility in women), excessive sweating, weight gain, swollen ankles/legs, sedation, drowsiness, clouded thinking, sleep apnea, paradoxical worsening of (hypersensitivity) to pain (also known as hyperalgesia).
Addiction: is a disease that occurs in some individuals. Taking opioids does not necessarily cause addiction, however, if you have risk factors for addiction (such as a strong family history of drug or alcohol abuse) or have had problems with drugs or alcohol in the past you must notify me since using strong painkillers will put you at greater risk. The extent of this risk is not certain.
Physical dependence: abruptly stopping the CS can create withdraw symptoms.
Tolerance: The body becomes "used to" the CS and maybe less effective.
Do not use any other substances (alcohol, cocaine, marijuana or other illegal substances) while taking the prescribed CS.
Proper use, storage, and disposal of CS: Take only as directed and by the person for whom the prescription is written. Keep all CS in a safe place, with the childproof containers. Controlled substances that are expired or unused can be taken to Las Vegas Metropolitan Police Department Substation. Disposal is anonymous and drop-off boxes are located inside substations, providing a secure method for disposal. If you are unable to get to one of the drop off locations, or if you have a small amount of medicine to dispose of, placing outdated or unneeded medications in the garbage is the best way to get rid of them.
For more information, visit the Southern Nevada Health District website: http://southernnevadahealthdistrict.org/health-topics/medication-disposal.php
Treatment plan and alternatives discussed: Th CS is prescribed in a limited quantity and has been prescribed following a visit, has been seen by a Provider and is warranted given the patient condition. There will be no refills for lost or stolen prescriptions. IN addition to this prescription, you are recommended to pursue non-pharmacologic treatment for pain including but not limited to psychotherapy and physical therapy. Over the counter options, non-opioic analgesics, heat and cold therapy were discussed as options of care.
Risk of CS exposure to fetus of childbearing age women: Newborn abstinence syndrome if the mother took opioids/opiates during pregnancy on a routine basis.
If the patient is an unemancipated minor, the risk that the minor will abuse, misuse or divert the CS and ways to detect those issues.