Pain Management Agreement – For Pain Management and Detox Patient Only

Instructions: patient is to take home before signing. Patient, pharmacy and Physician/Pain Program keep copies.

Patient: Today’s Date:

Opioids which are included in this consent

Butorphanol (Stadol) Methadone Codeine Morphine Codeine Compounds (Empirin) Nalbuphine (Nubain) Hydromorphone (Dilaudid) Oxycodone (Percodan, Percocet, Tylox) Hydrocodone (Vicodin, Loricet, Lortab) Levorphanol (Levo-Dromoran) Oxymorphone (Munorphan) Neperidine (Demerol) Pentazocine (Talwin) Propoxyphen (Darvon, Darvon-N, Darvocet) Subutex, Suboxone, Norco, Tylenol #3/#4.

This document gives your consent and your agreement to follow the program rules. You have reported to us that you have severe chronic pain, and believe you cannot relieve the pain without being dependent on one or more of the opioid drugs listed above. You must carefully read this consent and agreement. Take it home to discuss with your family, friends, attorney, doctor, minister, or any other party you desire before agreeing to opioid maintenance. The points listed below must be fully understood and agreed to by you before opioids can be habitually prescribed.

1. I fully understand that the opioids listed above and which I will be given will addict me.
2. I fully understand that the addiction which will result will probably last my lifetime and that statistics indicate that few people addicted to opioids are able to cease use and not relapse.
3. I am aware that the failure to use opioids will probably leave me in pain.
4. I have been told that there are many ways to relieve chronic pain and these include acupuncture, electrical stimulation, physical therapy, biofeedback, hypnosis, nerve blocks, mental health therapy, and non-opioid drugs. These methods have either been unsuccessfully tried by me, or are unacceptable to me as my only form of pain treatment, and at this time, I desire to be dependent upon opioids as my primary form of pain treatment.
5. I understand that I will be addicted, and if I discontinue the opioid drugs that I will likely suffer withdrawal symptoms which may include nausea and vomiting, pain, diarrhea, fever, seizures, flue-like syndrome, chills, headache, loss of appetite, depression and a return of my pain
6. I agree to take my opioid drugs as prescribed and will only obtain opioids from one pharmacy, except in emergency situations.
7. I will select one pharmacy to obtain my opioids, it is listed below, and I give my clinic my consent to release all of my current and future records and to discuss my case with the pharmacy. If I change pharmacies, I will inform the Physician/Pain Program and automatically give my permission to give them my current and future records. My chosen pharmacy is listed below.

8. I understand that the Physician/Pain Program will attempt to withdraw me from opioids at any time I desire, although I further understand that any withdrawal attempt may not be satisfactory and that it may result in increased pain. I also understand that the Physician/Pain Program will, at any time, refer me for any other type of pain treatment such as those listed in No. 4.
9. I understand that the use of any other mind altering drug such as a tranquilizer, stimulant, diet pill, sedative or alcohol with my opioid may impair my ability to safely drive a car.
10. I am aware that regular opioid use may have any of the following common side effects: constipation, nausea, itching, and abscesses and infections with injection. Females: If I should become pregnant, I understand that my baby would be addicted.
11. I understand that if I consume opioids in an amount above that which prescribed, sell them, or give them to someone, or use another mind altering drug not authorized by the clinic, the Physician/Pain Program, reserves the right to refuse to prescribe additional opioids, and provide further pain treatment.
12. Due to the highly dangerous and addictive nature of the opioids, I agree to only obtain them from the Physician/Pain program except in an emergency. If I obtain opioids from another clinic or physician, I will inform you. In this case, the Physician/Pain Program reserves the right to discontinue treatment and refer me elsewhere.
13. I fully understand that the Physician/Pain Program will not do any of the following:
1. Refill my opioid prescription by telephone;
2. Refill my opioid prescription before my scheduled appointment;
3. Refill my opioid prescription because my medication is lost or stolen.

I further understand that the Physician/Pain Program reserves the right to discontinue further treatment if I make any of these requests.

14. I fully understand that I cannot loan, give, or sell my opioids to another person. If I do this, the Physician/Pain Program will terminate my case and report me to the proper law enforcement agency.
15. I fully understand that I should keep a minimum of three day’s reserve supply of opioids at all times and never exhaust my supply. In the event that I miss a scheduled appointment, I will arrange for a clinic appointment within 72 hours.
16. I understand that I may leave the treatment program at any time and seek treatment elsewhere. In this event, the Physician/Pain Program will give me a one-week supple of opioids. I also understand that I can reapply to the opioid maintenance program again with a physician’s referral.
17. I fully understand that I will be given regular appointments at the Physician/Pain Program which must be kept. I also understand that I will receive other non-opioid pain treatments and diagnostic tests as determined by the Physician/Pain Program.
18. I fully understand that the Physician/Pain Program will consult me on my opioid medication requirements, and that I will tell the Physician/Pain Program my precise daily medication requirement by the number of oral dosages, injections, or suppositories that I will require.
19. I fully understand that the Physician/Pain Program will consult me on my opioid medication requirements, and that I will tell the number of oral dosages, injections, or suppositories that I will require.
20. I pledge to never take more opioid medications than prescribed or attend number the Physician/Pain Program in an over-medicated state. If I do, I understand that the Physician/Pain Program reserves the right to terminate my care.
21. I certify that there is no other person, including spouse, friend, parent, or sibling, living in my house who takes any of the opioid drugs, including heroin, which are listed at the top of this consent form.
22. I understand that my application to the Physician/Pain Program may be rejected if the Physician/Pain Program believes that I will be better served elsewhere.
23. The one pharmacy where I will obtain my opioid drugs is listed here:

Pharmacy Name:

Pharmacist, if known:

Address:

Phone Number:

I fully understand and agree to all of the points and rules listed above.

Name: Today’s Date: