903A South Greeley Highway, Cheyenne, WY 82007
Patient Agreement/Informed Consent for Opioid Therapy
I, ________________________________, have consulted with my provider at Pain Consultants of the Rockies, PC (Pain Consultants) and we have agreed to try opioid pain medications (narcotics) in the treatment of my chronic pain. I have been informed and clearly understand the following issues regarding the treatment of pain with these medications, as well as other analgesic (pain relieving) or sedative medications. I am aware that failure to abide by any of these conditions will be considered a breach of this contract and may result in the termination of the patient-provider relationship.
1. Monthly appointments: are required for prescription refills. Prescriptions will only be written during regularly scheduled appointments. If I cancel an appointment or miss one without calling, I understand that my prescriptions will not be refilled until I am seen in the clinic. I further understand that medications to assist with the symptoms of withdrawl can be written at my provider’s discretion.
a. The symptoms of withdrawl may include: sweating, anxiety, tremors, muscle aches, hot & cold flashes, abdominal cramps and diarrhea, nausea and vomiting.
2. Sole Providers: The providers at Pain Consultants will be the only providers to write prescriptions for sedative medications and/or analgesics of any sort. I will not accept prescriptions for these medications from any provider outside of Pain Consultants. Nor will I take medications prescribed to someone else or allow someone else to take medications prescribed to me.
3. Safe-keeping: I understand that I am responsible for the safe-keeping of my prescriptions and medications. If I lose them or they are stolen, I will not be given replacements and I could experience the symptoms of withdrawl.
4. Pharmacy: I agree to use only one pharmacy to fill my medications and to accept prescriptions for the generic form of my medications.
5. Medication dosages: I understand that my provider will prescribe my medications in dosages that he/she deems necessary. I will not adjust the amount of medication I take without first contacting Pain Consultants. If I should adjust the amount of medication I am to be taking and I run out early, I will not be given additional medications to “get me through” until my next appointment. I understand that increasing my dose without close supervision could lead to drug overdose, causing severe sedation, respiratory depression and death.
6. Side Effects: I am to notify my provider of any adverse side effects that I might experience while taking analgesic or sedative medications.
a. Adverse side effects include: over-sedation, nausea, vomiting, constipation, confusion, euphoria (feeling “high”), and dysphoria (feeling “low”). Other side effects can include: dizziness, sweating, itching, skin rashes, swelling, difficulty with urination, dry mouth, insomnia, disorientation, decrease sex drive and potency, and quick, sudden jerky movements of the arms or legs.
b. Motor Vehicles: If my medications should cause me to feel drowsy, dizzy or disoriented, I agree to not operate a motor vehicle or other heavy machinery which could cause bodily injury to me or others.
7. Treatment Goal: I understand the treatment goal is to improve my ability to function and/or work. In consideration of that goal, and that I am being given potent medication to help me achieve that goal, I agree to help myself by following better health habits (i.e. exercise, weight control and the cessation of alcohol and tobacco use) and by complying with the recommendations of my provider in the use of adjunctive therapies (i.e. physical therapy, psychological counseling). I further understand that if the use of these medications does not assist me in reaching this goal or if I refuse to participate in any adjunctive therapies, I will be tapered off of these medications and other methods of pain control will be explored.
8. Physical Dependence: It is clearly understood that the use of these medications may result in physical dependence. This condition is common to many drugs such as blood pressure medications, anti-anxiety medications and anti-seizure medications, as well as opioids.
9. Psychological Addiction: I understand that psychological addiction is a possible risk associated with opioid use. If I exhibit such behavior, I will be tapered off my medications and will no longer be considered a candidate for opioid therapy.
a. Psychological addiction can be recognized by: abuse of the drug(s) to obtain mental numbness or euphoria, drug craving behavior, “doctor shopping”, escalating drug usage without correlation with pain relief, and manipulative behavior toward the medical provider in order to obtain prescriptions.
10. Other Drugs: I may not take other drugs such as tranquilizers, sedatives or antihistamines without first contacting Pain Consultants. I may not use alcoholic beverages or “recreational drugs”. The combination of these drugs/beverages and those medications prescribed by my provider could produce profound sedation, respiratory depression, severe drop in blood pressure and possibly death. I agree to submit to random urine drug/alcohol testing at the discretion of my provider.
11. Pregnancy: If I am female, I agree to advise the clinic if there is even the slightest possibility that I am or may become pregnant. I understand that infants born to mothers on opioid therapy will likely be physically dependent at birth and could possibly have birth defects as a result of the medications.
12. Release of Information: I agree to allow Pain Consultants to have contact with other providers, Emergency Departments, pharmacies and urgent care facilities regarding this agreement. I further allow these outside entities to disclose to Pain Consultants any information required to ensure my adherence to this agreement.
13. Severability: I understand that if any provision of this agreement is determined to be invalid or unenforceable, the remainder of the agreement will remain in force.
14. Termination: I understand that this agreement may be terminated by either party upon 30 days written notice to the other. Delivery of such notice by US Postal Service Certified mail to my address of record shall be deemed sufficient notice. It is my responsibility to ensure that Pain Consultants has my current valid address. I may notify Pain Consultants of my intent to terminate our relationship in a similar fashion. I must send my notice to Pain Consultants’ main address.
I have read the above information (or it has been read to me), have received a copy of the agreement and all of my questions regarding my treatment with opioids have been answered to my satisfaction. I hereby give my consent to participate in opioid medication therapy.
Pharmacy Name & phone number: ____________________________
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