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 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.
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:
These side effects may be made worse if you mix opioids with other drugs, including alcohol and marijuana.
Dependence: This means it is possible that stopping the drug will cause you to miss or crave it.
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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If you have questions about the contents of this document, you can email the document owner.
Document Name: Opioid Contract
Agree & Sign