Informed consent for opioid medications/controlled substances

I agree to the below terms for prescribed medications as part of my treatment for chronic pain by signing this statement and accepting prescriptions.

• Medications are only prescribed and renewed through office visits. Prescribed medications will not be called in or picked up at the receptionist's desk.
• It is my responsibility to ensure that I have an office appointment scheduled prior to my medications running out.
• Medication will not be refilled early when more is taken than directed, lost, stolen or damaged.
• If my medication is stolen, I will report this to my local police department and obtain a stolen item report.
• I am also responsible for notifying my practitioner immediately if I am or may be pregnant.
• I understand that controlled substances have a potential for addiction and misuse.
• I understand that increasing my dose without the close supervision of my practitioner could lead to drug overdose, causing severe sedation, respiratory depression and even death.
• I understand that decreasing or stopping my medication without the close supervision of my practitioner could lead to drug withdrawal. Withdrawal symptoms may include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, abdominal cramps, nausea, vomiting and diarrhea. These symptoms can occur 24 to 48 hours after the last dose and can last up to three weeks.
• I am responsible for my opioid prescriptions. I understand that controlled substances will not be written for more than a one-month supply and will be filled at the same pharmacy.
• I will not allow other individuals to take my medications.
• I agree that I do not currently have any problems with substance abuse.
• I am not or will not be involved in the sale, illegal possession, diversion or transport of controlled substances.
• I will stop the use of opioid medications should my practitioner find this to be appropriate.
• I agree to participate in consults with specialists (i.e. psychiatry and psychology) as part of my comprehensive treatment.
  
• I understand the risks that are related to opioid medication. Common side effects include, but are not limited to nausea, vomiting, drowsiness, and constipation. Less common side effects are mental slowing, flushing, sweating, itching, sexual difficulties, psychological dependence, urinary difficulty and jerkiness. These side effects could occur at the beginning of my treatment and often go away within a few days. It is my responsibility to notify my practitioner of any side effects that continue or are severe, such as sedation or confusion.
• I am also responsible for notifying my pain practitioner if I am using benzodiazepines, (i.e. Valium or Ativan), sedatives (i.e. Soma or Fiorinal) and antihistamines (i.e. Benadryl). I understand that the combination use of the above drugs and opioids, as well as alcohol and opioids, may produce profound sedation, respiratory depression, decrease in blood pressure and even death. I cannot consume alcohol or use recreational drugs while on opioid pain medicine. If consumed, I will be terminated from the pain program.
• I agree to submit to urine and blood screens at any time as determined by my practitioner to detect the use of both prescribed and non-prescribed medication.
• I further understand that if I do not follow any of the above conditions or provisions, I may (at my practitioner's discretion) no longer receive any type of opioid medication. I also understand that if I have a problem or question with any of the above paragraphs, I must make an appointment to discuss this with the pain practitioner and receive clarification before a problem or crisis arises.
• I authorize the release of any information and hospital records by the pain physician or his/her designee, to other healthcare providers, my insurance company or other reimbursing agencies.
• I, _______________________________, have read the above information (or it has been read to me), and have received a copy of the contract. My questions regarding the treatment of pain with opioids have been answered to my satisfaction. I hereby give my consent to participate in opioid medication therapy when deemed appropriate by my pain practitioner.