Opioid Contract


Metamorphosis LTD

Name:   

DOB     

Controlled substance medications (narcotics: opioids, tranquilizers, barbiturates) can be very useful to treat painful conditions, but have a high potential for misuse and abuse and are therefore closely controlled by the government.

Possible benefits can include improved overall functioning, quality of life, improved sleep and increased ability to work and return to enjoyable hobbies and activity. It is unlikely you will be completely pain free. We expect you to have realistic pain goals.

To insure that these medications are used properly to treat my pain, I agree to follow the instructions listed below:

I will not request nor accept controlled substances from any other provider (i.e. Physicians including surgeons or dentists, NP’s, or PA-C’s) other individuals (neighbors, friends, relatives) or the emergency room while I am receiving such medication from my provider at Metamorphosis. In addition to being illegal to obtain controlled substances from multiple providers, it may endanger my health. I understand I cannot share my opioids with others, and must safely secure them from others.

I am responsible for my medications. They are like money in the sense that if the prescription or the medication itself is lost, misplaced, stolen or over used (less than 30 days) it is gone and will NOT be replaced.

I have been informed by my provider about opioid side effects, including normal physiologic effects of tolerance (need for more medicine to achieve the same pain relief), withdrawal (an uncomfortable reaction which may occur if I stop taking the medicine abruptly), and the abnormal effect of addiction (psychological dependence leading to abnormal behavior). Narcotics can adversely affect physical coordination, alertness, and sexual function, and hormone levels. Opiate therapy can cause severe constipation, nausea, drowsiness, breathing problems or difficulty with urination. Opiate therapy can cause infertility that may be permanent. Opiate therapy can increase my risk of infections especially pneumonia and death. My judgment in making business decisions and in operating equipment such as automobiles may be impaired and is discouraged by Metamorphosis.

I authorize my provider to obtain information from my pharmacy and to provide a copy of this contract to my pharmacy. I agree to waive any applicable privilege or right of privacy and confidentiality with respect to communication of controlled substance usage.

I will not use any illegal controlled substance including kratom, cocaine, heroin, stimulants, or other hallucinogens. If I am found to be positive for an illicit substance on urinalysis I understand that I will no longer be prescribed opioids from this practice.

I have been informed that the combination of alcohol and opioids increases the sedative effect of both, combination could lead to respiratory depression increasing the risk of death from overdose. If only on a short acting medication I realize that I must not take my medication 6 hours prior to or after drinking an alcoholic beverage. If on a long acting medication I realize that I may not consume alcoholic beverages at any time. I understand this policy and realize if I come up positive for alcohol while on a long acting opioid I will not be prescribed opioids from the practice.

I authorize my provider to order a urine or oral test for controlled drug screening at any time, at my own expense, to determine if my medications are being taken properly. Altering or failing to submit urine for screening upon request will lead to immediate termination.

Obtaining opioids for the purpose of selling, giving or sharing with others as well as altering prescriptions in any way are all illegal activities and may lead to immediate dismissal from the practice as well as reporting to the police or DEA.

I agree to participate in psychiatric or psychological assessments, if necessary.

I understand that this provider may stop prescribing, or change the treatment plan if:

  • I do not show any improvement in pain from opioids or my physical activity has not improved.
  • My behavior is inconsistent with the responsibilities outlined in this document.
  • I give, sell or misuse the opioid medications.
  • I develop rapid tolerance or loss of improvement from the treatment.
  • I obtain opioids from providers other than this one.
  • I refuse to cooperate when asked to get a drug screen.
  • If an addiction problem is identified as a result of prescribed treatment or any other addictive substance.
  • If I am unable to keep follow up appointments

I understand that office staff are here to ensure the smooth operation of the clinic, and that verbal or physical abuse of the staff will be grounds for dismissal from care.

Side Effects

You should be aware of the potential side effects of opioids such as decreased reaction time, clouded judgment, drowsiness and tolerance. Also, you should know about the possible danger associated with the use of opioids while operating heavy equipment or driving. Side effects include:

  • Confusion or other change in thinking abilities
  • Nausea
  • Constipation
  • Vomiting
  • Enlarged breasts in men
  • Loss of sexual function
  • Infertility
  • Impotence
  • Problems with coordination or balance that may make it unsafe to operate dangerous equipment or motor vehilces
  • Sleepiness or drowsiness
  • Depression
  • Loss of muscle strength and mass
  • Changes in hormonal levels
  • Increased risk of infections, particularly pneumonia
  • Mixing with benzodiazepines and muscle relaxers may increase the risk of overdose and death.
  • Breathing to slowly -overdose can stop your breathing and lead to death
  • Anxiety
  • Dry mouth
  • Menstrual irregularities
  • Bone fractures due to opioid induced osterporosis

These side effects may be made worse if you mix opioids with other drugs, including alcohol and marijuana.

Risks

  • Physical dependence. This means that abrupt stopping of the drug may lead to withdrawal symptoms characterized by one or more of the following:
  • Runny nose
  • Abdominal cramping
  • Rapid heart rate
  • Diarrhea
  • Sweating
  • Nervousness
  • Difficulty sleeping for several days
  • Goose bumps
  • Dependence:  This means it is possible that stopping the drug will cause you to miss or crave it.

  • Tolerance: This means you may need more and more of the drug to get the same effect
  • Addiction. This means that you may use the medication inappropriately due to cravings rather than pain, losing the ability to control your use.

I have read this document, understand and have had all my questions answered satisfactorily. I consent to the use of opioids to help control my pain and I understand that my treatment with opioids will be carried out as described above.

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Metamorphosis Pain Management https://www.metamorphosispain.com
Signature Certificate
Document name: Opioid Contract
Unique Document ID: 8ce44648659b0cfac4adddcb5ae960b24de6dde3
Timestamp Audit
2017-05-07 23:08:09 MDTOpioid Contract Uploaded by Lisa Pearson - lisa@metamorphosispain.com IP 208.117.75.130