Opioid Therapy Patient-Provider Agreement
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, physicaltherapy, medication therapy, psychologicalcounseling, and exercise and weigh loss programs. During the course of your treatment, your physician may or may not prescribe medications. 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 carefullv. as these policies will be enforced. lf vou do not understand anv 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 aFreement stating vour understanding and compliance before receiving anv pain medication.
Please Initial the following:
The pain management treatment plan has been discussed, understood and agreed on 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 medication.
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 medications to the best of your ability. lf 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
medication 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 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 orvomiting,
trouble driving and/or operating machinery. Taking more opioids than prescribed or mixing sedatives, benzodiazepines or
alcohol can result in fatal respiratory depression.
You agree to only take pain medication prescribed by The Spine and Pain Center providers, 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 your physician. You understand that taking more medication than prescribed or taking
pain medication from another source may lead to 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. lf you are prescribed these medications by another provider at any time during your treatment at
The Spine and Pain Center you are obligated to notify your physician
You understand addiction is a primary, chronic neurobiological disease with genetic, psychological and environmental
factors influencing lts development and manifestation. lt 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. lf you have a history of
alcohol or drug misuse/addiction, you must notify your physician of such history.
You understand your medications are required o last for the duration prescribed. You must safeguard and protect
your prescription medications, including keeping them in a safe place and away from children. lt is recommended you keep
them in a locked safe or cabinet. You must not share, sell or otherwise permit others to have access to these medications. lf you
fail to meet the prescribed timeline, your medication is lost, misplaced, destroyed or stolen, early prescription refills will not be
permitted. Your physician reserves the right to choose to taper or discontinue medications that are lost or stolen,
lf you intend to stop taking your medication, have a negative reaction, or failto submit your prescription refill
request according to the policies below, you must discuss the 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. lf your physician discontinues your medicatlons as a part of the
treatment plan, non-compliance or dismissalfrom the practice, you will be provided with a weaning ortapering dose to avoid
negative withdrawal effects if deemed appropriate by your physician.
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 pharmacies or other professionals who provide you healthcare. Please list your pharmacy
below.
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The following are policies related to prescription refills: (Please Initial)
You understand that you must be assessed by our providers prior to every opioid prescription.
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
su bstances.
Patients will only be seen during office hour: Monday-Thursday 8:00am-5:00pm and Friday 8:00am-12:00pm. No
exceptions will be made.
lf your prescription expires you must return the prescription to our office before another prescription will be issued.
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. lf you live
outside of a 60 miles 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 discontinuation of medications and/or dismissalfrom our
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 medications.
Failure or refusalto provide a sample for drug testing will be viewed as non-compliance and may result in
discontinuation of medications and/or dismissal from our practice.
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 The Spine and Pain
Center immediately if you have a reaction or are allergic to any prescribed medication.
You may be asked to obtain a Narcan or opioid "overdose kit", available from local pharmacies without a
prescription. Failure to comply may result in discontinuation of medication.
(FEMALE PATIENTS ONLY) To the best of your knowledge, you are NOT pregnant. You agree to use appropriate
contraceptive during your course of treatment. lf you do become pregnant or suspect pregnancy, you will notify your
physician at The Spine and Pain Center IMMEDIATELY. You understand there are potential risks associated with pregnancy and
chronic opioid therapy. There is no guarantee that you or your unborn child will not experience significant or serious side
effects related to the medications you are prescribed.
You must keep your scheduled appointments. lf you are unable to make it to an appointment, you must provide a 24-
hour notice to cancel. lf you fail to appear or give the required notice of cancellation, your medications may not be refilled, lf
you failto appear for more than two appointments, you may be dismissed from our practice.
This clinic and/or physician retain the right to discuss your treatment with law enforcement officials during an official
investigation.
You understand that 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 your medications. lf deemed
appropriate by your physician, a weaning dose will be provided. lf you wish to terminate this agreement, please contact our
office for guidance.
Your healthcare team at The Spine and Pain Center is dedicated to your safety and the control of your pain and we must have
vour 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.
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 these terms and understand that failure to do so may result in
termination of the physician/patient relationship and/or termination from this medical practice.
I understand that typing my name in this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
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