Stimulant Informed Consent Form

This consent form outlines the agreement between the patient and Aspire Medical Group regarding the use of central nervous system stimulants, referred to herein as 'stimulants,' as part of the patient’s treatment plan. It is crucial for patients to understand the benefits, risks, and responsibilities associated with stimulant use to ensure safe and effective treatment. The following information aims to educate the patient on the risks associated with stimulant use, facilitating understanding and consent to a treatment contract.

Prescription stimulants are classified as Schedule II controlled substances due to their potential for abuse and dependence. They are primarily used to treat conditions such as:

• Attention Deficit Hyperactivity Disorder (ADHD)
• Excessive daytime sleepiness in narcolepsy
• Binge eating disorders
• Occasionally, treatment-resistant depression

Benefits When Used as Directed

• When prescribed and used under medical supervision, stimulants can offer significant benefits such as improved concentration, enhanced mood and alertness, improved academic and social functioning, and better executive functioning, including planning and decision-making.

Side Effects and Risks of Stimulants

• Common side effects include loss of appetite, insomnia, headache, stomach ache, dry mouth, increased heart rate, and nervousness.
• Rare side effects may include changes in heart rhythm, decreased growth in children, psychiatric effects (e.g., agitation or hallucinations), visual disturbances, and priapism (prolonged erection) in methylphenidate formulations.
• Serious side effects, though exceedingly rare, may include sudden death, heart attack, or stroke.

For a comprehensive list of adverse effects, please refer to the FDA Medication Guide

Long-Term Use

Stimulants are often used long-term for ADHD when continuous monitoring demonstrates sustained efficacy. However, long-term use may lead to physiological dependence and tolerance, requiring higher doses to maintain efficacy. Withdrawal symptoms may occur if the medication is abruptly discontinued. There is a potential risk of growth suppression in children, so periodic drug holidays may be recommended to mitigate these risks.

Safety and Monitoring

Adherence to the prescribed dosage and regular monitoring by healthcare providers are essential for minimizing side effects and ensuring the safe and effective use of stimulant medications.

Emergency Contact

If you experience any severe side effects, such as difficulty breathing, chest pain, confusion, or any other unusual symptoms, contact your provider immediately. If the situation is severe, call 911 or seek emergency medical care.

Non-Stimulant Medications

• Atomoxetine (Strattera) is a non-stimulant medication often used to treat ADHD by increasing norepinephrine levels in the brain. It tends to have fewer side effects related to insomnia and appetite suppression.
• Guanfacine (Intuniv) and Clonidine (Kapvay) are alpha-2 adrenergic agonists that help manage ADHD symptoms by affecting receptors in the brain that influence attention and impulse control.
• Certain antidepressants, such as bupropion (Wellbutrin), can be prescribed for ADHD and mood disorders. These medications may help improve focus and reduce hyperactivity and impulsivity.

Behavioral Therapy

• Cognitive Behavioral Therapy (CBT) focuses on teaching skills for managing focus, attention, organization, and emotional regulation. It can be particularly beneficial for people with ADHD or those looking to improve executive function.
• Behavioral Parent Training (BPT) is an approach for children with ADHD, involving teaching parents strategies to manage their child’s symptoms through positive reinforcement, structure, and consistency.
• ADHD coaching focuses on developing practical strategies to improve time management, organization, and goal setting.

Lifestyle Modifications

• Dietary adjustments, including a diet rich in omega-3 fatty acids (e.g., fish oil supplements), proteins, and reducing sugar intake, can help manage symptoms.
• Regular physical activity has been shown to improve focus, attention, and cognitive performance. Exercise stimulates the brain to release neurotransmitters that enhance focus.
• Mindfulness and meditation techniques, such as mindfulness-based stress reduction, can help individuals with ADHD improve their ability to focus and manage impulsivity.

1. Personal Use: I understand that my stimulant prescription is intended for personal use only. Sharing, selling, or trading my medication is prohibited and is a violation of clinic policy and federal law. Such actions will result in the discontinuation of my prescription and termination of treatment.

2. Provider Notification: I will not seek stimulant medications from other providers without notifying my prescriber.

3. Controlled Medication Disclosure: I will not obtain other controlled medications without first informing my prescriber. If I obtain additional controlled substances, such as narcotic medication from an emergency room physician, I will notify my prescriber immediately by calling the office at (617) 991-9151.

4. Medication Disclosure: I will disclose all prescribed and over-the-counter medications to avoid harmful interactions.

5. Dosage and Frequency: I will not alter the dosage or frequency of my medication without first consulting my prescriber. Any changes in dosing must be approved during scheduled appointments and not via phone, after hours, or on weekends.

6. Proper Use: Stimulants must be taken strictly as prescribed. Altering the form (e.g., injecting, crushing, or snorting) is prohibited.

7. Drug and Alcohol Interaction: I will not combine my medication with other drugs or alcohol without consulting my prescriber. Combining stimulants with alcohol or illicit drugs can be dangerous. I understand that use of alcohol, marijuana, or other illegal substances while taking stimulants may jeopardize my continued treatment.

8. Appointment and Refill Policy: I am responsible for scheduling regular appointments and contacting the office at least 72 hours before running out of medication for refills. Refills will only be processed during office visits or regular office hours.

9. Renewal Conditions: Renewals of my stimulant prescription are contingent upon my adherence to scheduled appointments and compliance with treatment. If I need to cancel an appointment, I agree to do so at least 24 hours in advance by calling (617) 991-9151.

10. No Early Refills: I understand that I will not be able to obtain early refills or replacements for lost, stolen, or damaged stimulant medication.

11. No Pharmacy Refill Requests: I understand that pharmacy refill requests for controlled medications, including stimulants, will not be accepted.

12. Storage and Disposal: Stimulant medications must be stored securely, out of reach of children and pets. Unused or expired medication should be returned to the pharmacy for proper disposal.

13. Substance Use Disclosure: I will inform my prescriber of any alcohol or drug use, both past and present, as well as any history of alcoholism or addiction.

14. Toxicology Screenings: I consent to random urine or serum toxicology screenings as requested by my prescriber. I understand that further prescriptions or refills are contingent upon completion of the requested screening. I am responsible for any out-of-pocket expenses associated with these screenings.

15. Pill Counts: I consent to random pill counts as requested by my prescriber. If requested, I will bring my medication in its original container to my next appointment for verification. Further refills will depend on completion of the requested pill count.

16. Substance Use Screening and Consequences: I understand that the presence of unauthorized substances, or the absence of prescribed medications in screenings, may result in a referral for substance abuse assessment or discharge from the practice. Unexpected results may also lead to discontinuation of my stimulant prescription.

17. Adjunctive Management Programs: I agree to participate in adjunctive management programs as recommended by my prescriber, including psychological testing, psychotherapy, behavioral modification, school-based interventions, or job modifications.

18. Pregnancy: If I become pregnant or intend to become pregnant during treatment, I will inform my prescriber promptly. This is essential to discuss the risks to the fetus and consider tapering options. I absolve Aspire Medical Group and my prescriber of any liability for harm to myself or my unborn child if I fail to notify my prescriber of pregnancy.

19. Information Sharing: I consent to the sharing of my medical information with other healthcare professionals involved in my care, if deemed medically necessary. I acknowledge that my prescriber has the authority to disclose relevant information for comprehensive care.

20. Prescription Monitoring: I understand that my prescriber will verify that I am only receiving controlled substances that I have reported, and they will review the Massachusetts Prescription Drug Monitoring Program as required by law.

21. No Exception Requests: I understand and agree that I will not request variations or exceptions to this agreement. Any concerns should be discussed during scheduled appointments or as directed by my healthcare provider. 

• I certify that I have read this form in its entirety and fully understand its contents. I have been given the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
• I consent to the use of stimulants as part of my treatment plan and understand that this treatment will be governed by the terms outlined in this agreement.
• I have informed my healthcare provider of all my medical conditions, known allergies, past adverse reactions, and all medications and supplements I am currently taking.
• I understand that failure to comply with this agreement may result in the discontinuation of my stimulant prescription and/or termination from the practice. I acknowledge that my prescriber reserves the right to adjust or discontinue treatment as necessary.
• I acknowledge that no guarantees have been made regarding the outcome of this treatment.
• By signing this form, I voluntarily consent to treatment, agree to the use of electronic records and signatures, and confirm that I have the legal authority to be bound by this agreement. I voluntarily accept the risks, conditions, and terms outlined in this document.

 

By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.