The purpose of this agreement is to give you information about the medications you will be taking for pain management and to assure that you and your physician comply with all state and federal regulations concerning the prescribing of controlled substances. 

Our goal is to provide you with the best quality treatment of your pain. To accomplish this goal, your physician will customize your treatment plan to best fit your healthcare needs. Your pain management treatment plan may include, but is not limited to, injection therapy, physical therapy, medication therapy, psychological counseling, relaxation therapy and exercise, and weight loss programs. When opioids and other controlled medications are the best option, it is important to review and follow the policies to ensure your safety and our continued ability to treat you in the most effective way possible.

Please read this carefully, as these policies will be enforced. If you do not understand any of the information below or require additional clarification on the policies of this practice regarding prescribed medication, please ask. You are required to initial next to each section and sign this agreement stating your understanding and compliance before receiving any pain medication.

The pain management treatment plan has been discussed, understood, and agreed to by you and your physician. You understand the reason why this prescription is necessary. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to you, and you still desire to receive medications for the treatment of your chronic pain. You are expected to comply with and actively participate in all aspects of the plan and the responsible use of medications.

You understand that opioids and other controlled medications are prescribed to increase your function, activity level, and quality of life. These medications may reduce your pain, but may not provide complete relief. Your treatment plan will be evaluated at least every three months. You agree to fully communicate your pain level, functional ability, and any side effects of the medication to the best of your ability. If these aspects do not improve with these medications, the risks of the medication outweigh the benefits or there is the potential of negative effects related to another medical condition or medication, your provider may reduce or eliminate the medications from your treatment plan.

You agree to inform your physician of all medications you are taking, including herbal remedies, since Opioid medications can interact with over-the-counter medications and other prescribed medications. This is especially true of cough syrup that contains alcohol, codeine or hydrocodone. 

To ensure your safety, it is your obligation and responsibility to take medications exactly as prescribed by your physician (dose and frequency). You understand that these medications can lead to physical dependence and/or addiction, and can be associated with other risks including, but not limited to, decreased effectiveness, physical and psychological dependence, confusion, itching, difficulty urinating, constipation, allergic reactions, decreased sex drive, drowsiness, nausea or vomiting, trouble driving and/or operating machinery. Taking more opioids than prescribed or mixing sedatives, benzodiazepines or alcohol with opioids can result in fatal respiratory depression.

You agree to only take pain medications prescribed by the providers of this medical practice. Do not take any pain medication given to you by another person or provider (health, dental, clinic or emergency department) or increase your dosage without authorization from this physician. You understand that taking more medication than prescribed or taking pain medication from another source may lead to an overdose that could result in slowed or stopped breathing, brain injury from lack of oxygen, coma, or death.

You understand that there is an increased risk of overdose associated with the use of opioids in combination with medications used to treat anxiety disorders, panic attacks, insomnia or seizures (benzodiazepines), alcohol and other central nervous system depressants. If you are prescribed these medications by another provider at any time during your pain management treatment, you must inform your physician immediately. You must also inform all other treating healthcare providers of the medications being prescribed as a part of your pain management treatment plan.

You understand this clinic has a policy of limiting dosing to 90mg of Morphine or equivalent maximum doses as outlined in the CDC Opioid Treatment Guidelines and state law. You agree to comply with such policies and dosing limitations.

You understand addiction is a primary, chronic neurological disease with genetic, psychosocial and environmental factors influencing its development and manifestation. It is characterized by behavior that includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and cravings. If you have a history of alcohol or drug misuse/addiction, you must notify the physician of such history.

You understand your medications are required to last for the duration prescribed. You must safeguard and protect your prescription medications, including keeping them in a safe place and away from children. It is recommended that you keep them in a locked safe or cabinet. You must not share, sell, or otherwise permit others to have access to these medications. If you fail to meet this prescribed timeline, your medication is lost, misplaced, destroyed, or stolen, early prescription refills will not be permitted. This physician reserves the right to choose to taper or discontinue medications that are lost or stolen.

If you intend to stop taking your medications, have a negative reaction, or fail to submit your prescription refill request according to the policies below, you must discuss this discontinuation of medications with your physician prior to doing so. Sudden discontinuation of medications may result in withdrawal, including nausea, shakiness, sweating, rapid heart rate, diarrhea, high blood pressure, pain, or severe nervousness. If your physician discontinues your medications as a part of the treatment plan, non-compliance or dismissal from the practice, you will be provided with a weaning or tapering dose to avoid negative withdrawal effects.

All prescriptions will be obtained at one pharmacy, when possible. Should the need to change pharmacies arise, you must inform our office immediately. The prescribing physician and staff have permission to discuss history, diagnostic, and treatment details with dispensing pharmacists or other professionals who provide you healthcare.

The following are policies related to prescription refills:

You understand you must be assessed by our providers prior to every opioid prescription refill.

You must inform your provider of any changes in other prescribed or OTC medications, medical condition, surgical history, relevant family history, social history, or civil actions related to the use of opioids, narcotics, alcohol, or illegal substances.

You agree to comply with medication compliance monitoring as needed. These include, but are not limited to:

Random pill counts may be required and must be responded to within the given timeframe. If you live outside of a 60-mile radius from our office, your local pharmacy or doctor’s office may perform the requested pill count and report the results to our office. Counts that are inconsistent or failure to comply with a requested pill count will be viewed as non-compliance and may result in dismissal from this practice.

Random urine or blood drug screenings may be requested. Presence of illegal, unauthorized substances, absence of prescribed medications or other abnormal results may result in discontinuation of your controlled medications. Failure or refusal to provide a sample for drug testing will be viewed as non-compliance and may result in dismissal from our practice.

This clinic and/or physician retains the right to discuss your treatment with law enforcement officials during any official investigation.

You agree to read the package inserts and prescription bottle labels for any prescribed medications. You will discuss any questions or concerns regarding contraindications or reactions with your physician. You will inform this clinic immediately if you have a reaction or are allergic to any prescribed medication.

You will be asked to obtain a Narcan or opioid “overdose kit”. It will be prescribed at the first visit that you are prescribed opioids. We ask that you maintain Narcan that has not expired. 30-60 days prior to the expiration of your Narcan prescription, tell your provider so that a new prescription can be sent. Failure to comply may result in the discontinuation of medication.

(Female Patients Only) To the best of your knowledge, you are NOT pregnant. You agree to use an appropriate contraceptive during your course of treatment. If you do become pregnant or suspect pregnancy, you will notify your physician IMMEDIATELY. You understand there are potential *risks associated with pregnancy and chronic opioid therapy. You or your unborn child may experience significant or serious side effects related to the medications you are prescribed.

3 or 3 *(Patients Currently Pregnant) The short-term use of opioids for acute pain can be safe when prescribed by your physician. Long-term use of opioids can be harmful for your unborn baby. There is also a risk of neonatal abstinence syndrome with the use of opioids that can require in-hospital treatment of the baby after birth. You should discuss alternatives to opioids for pain control, but non-steroidal anti-inflammatory drugs should not be used in the third trimester of pregnancy.

You must keep your scheduled appointments. If you are unable to make it to an appointment, you must provide 24-hour notice to cancel. If you fail to appear or give the required notice of cancellation, your medications may not be refilled. If you fail to appear for more than 2 appointments, you may be dismissed from our practice.

You understand that if anytime, your provider has reason to believe that you are not in compliance with the terms of this agreement or your treatment plan, the provider may terminate this agreement and medications with a proper weaning dose. If you wish to terminate this agreement, please contact our office for guidance.

Your health care team is dedicated to your safety and the control of your pain, and we must have your cooperation to achieve these goals. The agreement is designed to ensure your safety and to help us and you comply with the standards of good medical care, as well as, state and federal laws related to chronic opioid therapy. Please sign below.

The above agreement has been explained to me by my physician or clinic staff. Any and all questions or concerns have been answered or addressed to my satisfaction. I agree to comply with the terms contained herein and understand that failure to do so may result in termination of the physician/patient relationship and/or termination from this medical practice.