CONTRACT FOR CONTROLLED SUBSTANCE PRESCRIPTIONS
1. I am responsible for my controlled substance medications. If the prescription or medication is lost, flushed in error, misplaced, stolen, or if I use it up sooner than prescribed, I understand that it will not be replaced. I am aware that I must report stolen medications to the police.
2. I will not request nor accept the controlled substance medication from any other physician or individual while I am receiving such medication from my doctor at Belmont Medical Associates. Besides being illegal to do so, it may endanger my health. The only exception is if it is prescribed while I am admitted in a hospital, or discussed with my Belmont Medical Associates physician.
3. Periodic unannounced testing of my blood and/or urine may be performed to determine my adherence to the plan of care and to assess for toxic levels of medications or potential drug interactions.
4. Refills of controlled substance medication:
a) will be made only during regular office hours, 9:00 am to 4:00 pm Monday through Friday, in-person, once each month during a scheduled office visit. Refills will not be made at night, on holidays, or weekends.
a) will not be made as an "emergency", such as on Friday afternoon because I suddenly realize I will "run out tomorrow". I must keep track of my medication and plan ahead. I will call at least 24 hours ahead if I need assistance with a controlled substance medication prescription.
c) will not be made if I "run out early". I will not take any more medication than prescribed unless I speak with my doctor or nurse at the office first. If I overuse my medication I will go through withdrawal. Withdrawal is a severe "flu-like" illness caused by the sudden cessation of opioids.
d) will only be given if I use one pharmacy for all my controlled substance medications and give my doctor at Belmont Medical Associates full permission to communicate with the pharmacist about my medical care and medications.
The name of my pharmacy is_______________________________and their telephone number is_______________________.
5. I understand that if I violate any of the above conditions, my controlled substance prescriptions and/or treatments at Belmont Medical Associates may be ended immediately. If the violation involves obtaining controlled substances from another individual, as described above, I may also be reported to my primary physician, local medical facilities, and other authorities.
6. I will not take any "street" drugs. I understand that taking any non-prescribed drugs may be grounds for expulsion from Belmont Medical Associates.
7. I understand that the main treatment goal is to improve my ability to function and/or work. I am being given a potent medication to reach that goal. I agree to help myself by following better health habits, specifically involving exercise, weight control, and the avoidance of tobacco and alcohol. I understand that only through following a healthier lifestyle can I hope to have the most successful outcome to my treatment.
8. I understand that if the treatment team feels that I am not taking my medications in the prescribed manner or the medications are not improving my ability to function then I will be weaned off the medications.
9. I have been fully informed by my doctor and the staff about the psychological dependence (addiction) of a controlled substance, which I understand is rare. I know that some persons may develop tolerance, which is the need to increase the dose of the medication to achieve the same effect of pain control, and I do know that I will become physically dependent on the medication. This will occur if I am on the medication for several weeks. When I stop the medications, I must do so slowly and under medical supervision or I may have withdrawal symptoms.
Signature: ____________ _________________
Print Patient's Name: _______________________DOB_____________
Doctor's signature:________________________
Print Doctor's Name:_______________________
Signed on the______day of the month of ___________in the year______
at 725 Concord Avenue, Cambridge, MA 02138
2. I will not request nor accept the controlled substance medication from any other physician or individual while I am receiving such medication from my doctor at Belmont Medical Associates. Besides being illegal to do so, it may endanger my health. The only exception is if it is prescribed while I am admitted in a hospital, or discussed with my Belmont Medical Associates physician.
3. Periodic unannounced testing of my blood and/or urine may be performed to determine my adherence to the plan of care and to assess for toxic levels of medications or potential drug interactions.
4. Refills of controlled substance medication:
a) will be made only during regular office hours, 9:00 am to 4:00 pm Monday through Friday, in-person, once each month during a scheduled office visit. Refills will not be made at night, on holidays, or weekends.
a) will not be made as an "emergency", such as on Friday afternoon because I suddenly realize I will "run out tomorrow". I must keep track of my medication and plan ahead. I will call at least 24 hours ahead if I need assistance with a controlled substance medication prescription.
c) will not be made if I "run out early". I will not take any more medication than prescribed unless I speak with my doctor or nurse at the office first. If I overuse my medication I will go through withdrawal. Withdrawal is a severe "flu-like" illness caused by the sudden cessation of opioids.
d) will only be given if I use one pharmacy for all my controlled substance medications and give my doctor at Belmont Medical Associates full permission to communicate with the pharmacist about my medical care and medications.
The name of my pharmacy is_______________________________and their telephone number is_______________________.
5. I understand that if I violate any of the above conditions, my controlled substance prescriptions and/or treatments at Belmont Medical Associates may be ended immediately. If the violation involves obtaining controlled substances from another individual, as described above, I may also be reported to my primary physician, local medical facilities, and other authorities.
6. I will not take any "street" drugs. I understand that taking any non-prescribed drugs may be grounds for expulsion from Belmont Medical Associates.
7. I understand that the main treatment goal is to improve my ability to function and/or work. I am being given a potent medication to reach that goal. I agree to help myself by following better health habits, specifically involving exercise, weight control, and the avoidance of tobacco and alcohol. I understand that only through following a healthier lifestyle can I hope to have the most successful outcome to my treatment.
8. I understand that if the treatment team feels that I am not taking my medications in the prescribed manner or the medications are not improving my ability to function then I will be weaned off the medications.
9. I have been fully informed by my doctor and the staff about the psychological dependence (addiction) of a controlled substance, which I understand is rare. I know that some persons may develop tolerance, which is the need to increase the dose of the medication to achieve the same effect of pain control, and I do know that I will become physically dependent on the medication. This will occur if I am on the medication for several weeks. When I stop the medications, I must do so slowly and under medical supervision or I may have withdrawal symptoms.
Signature: ____________ _________________
Print Patient's Name: _______________________DOB_____________
Doctor's signature:________________________
Print Doctor's Name:_______________________
Signed on the______day of the month of ___________in the year______
at 725 Concord Avenue, Cambridge, MA 02138
INFORMED CONSENT FOR OPIOID MANAGEMENT
The purpose of this informed consent agreement is to give you information about the medications you will be taking for pain management and to assure that you and your physician/health care provider comply with all state and federal regulations concerning the prescribing of controlled substances. A trial of opioid therapy can be considered for moderate to severe pain with the intent of reducing pain and increasing function. The physician’s goal is for you to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks and benefits of using opioids to treat pain.
I have agreed to use opioids (morphine-like drugs) as part of my treatment for chronic pain. I understand that these drugs can be very useful, but have a high potential for misuse and are therefore closely controlled by the local, state, and federal government.
Physical dependence is common to many drugs such as blood pressure medications, anti-seizure medications, and opioids. It results in biochemical changes such that abruptly stopping these drugs will cause a withdrawal response. It should be noted that physical dependence does not equal addiction. One can be dependent on insulin to treat diabetes or dependent on prednisone (steroids) to treat asthma, but one is not addicted to the insulin or prednisone.
Addiction is a primary, chronic neurobiologic 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. This means the drug decreases one’s quality of life. If the patient exhibits such behavior, the drug will be tapered and such a patient is not a candidate for an opioid trial. He/she will be referred to an addiction medicine specialist.
Tolerance means a state of adaptation in which exposure to the drug induces changes that result in a lessening of one or more of the drug’s effects over time. The dose of the opioid may have to be titrated up or down to a dose that produces maximum function and a realistic decrease of the patient’s pain.
I understand that increasing my dose without the close supervision of my physician could lead to drug overdose causing severe sedation and respiratory depression and death.
I should inform my physician of all medications I am taking, including herbal remedies. Medications like Valium, Xanax or Ativan; sedatives such as Soma, Fiorinal; antihistamines like Benadryl; herbal remedies, alcohol, and cough syrup containing alcohol, codeine, or hydrocodone can interact with opioids and produce serious side effects.
I understand that decreasing or stopping my medication without the close supervision of my physician can lead to withdrawal. Withdrawal symptoms can include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, “goose flesh”, abdominal cramps, and diarrhea. These symptoms can occur 24-48 hours after the last dose and can last up to 3 weeks.
I understand the above explanation of the risks associated with opioid usage.
Signed:
Printed name: DOB:
Date signed:
