Controlled Substance Contract

understand and voluntarily agree to the following statements

I will keep (and be on time) for all my scheduled appointments with the doctor and other members of the treatment team.

I will participate in all other types of treatment that I am asked to participate in.

I will keep the medications safe, secure and out of reach of children. If medicine is lost or stolen, I understand it will NOT be replaced.

I will take my medications as instructed and not change the way I take it without first talking to the doctor or other members of the treatment team.

I will not call between appointments, at night, or on weekends looking for refills.

I understand that prescriptions will be filled only during scheduled office visits with the treatment team.

I will make sure I have an appointment for refills.

I will always treat the staff at the office respectfully. I understand that if I do not, my treatment will be stopped.

I will not sell the medication or share it with others. I understand that if I do, my treatment will be stopped.

I will let the doctor speak to all other doctors or providers that I see.

I will tell the doctor all other medications that I take and let him know right away if I have a prescription for a new medication.

I will agree to do a drug screen when required.

I will use only one pharmacy to get all my medications:

I will not get any opioid pain medicines or other medications that can be addictive such as benzodiazepines(Klonopin, Xanax, Valium) or stimulants (Ritalin, amphetamine) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekend. If this occurs I will call the next business day.

I will not use illegal drugs such as heroin, cocaine or amphetamines. I understand that if I do, my treatment will be stopped.

I will come in for drug testing and counting of my pills within 24 hours of being called. I understand that I must make sure the office has current contact information to reach me and that any missed drug screens will be considered positive for drugs.

I understand that I may lose my right to treatment in this office if I break any part of this agreement.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Treatment Agreement

I understand that this doctor may stop prescribing opioids 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.
• I give, sell or misuse the opioid medications.
• I develop rapid tolerance or loss of improvement from the treatment.
• I obtain opioids from another physician.
• I refuse to cooperate when asked to get a drug screen.
• If an addiction problem is identified because of prescribed treatment or any other addictive substance.
• If I am unable to keep follow-up appointments.

Controlled Substance Policy

There is currently an opioid crisis in Louisiana and the United States. More people are dying of drug overdoses than in car accidents.

The United States government and particularly the state of Louisiana is very concerned about this and has changed the way that pain medications, antigenic anxiety medications, and muscle relaxants can be prescribed in the state of Louisiana.

As an orthopedic surgeon, I can write for narcotics only for acute pain such as fractures, acute injuries or after surgery.

If you have chronic pain defined as any pain over three months I cannot write pain medication for you. You need to see a pain doctor. If you are here to get narcotics for chronic pain, please cancel your appointment and either contact your primary care provider or your insurance for a referral to a pain physician. I cannot help you. And I cannot write your medication for a month or two until you find a pain physician.

If you have an acute injury, we do have multiple rules we have to abide by.

First giving you a prescription for narcotics for pain is a trial. If it is ineffective in decreasing your pain, increasing your function or giving you side effects the medication will be discontinued.

Secondly, there are risks in taking narcotics for pain. Some but not all are outlined below.

1. Safety: Most people can take these drugs safely, but some do experience effects.
2. Side Effects: Most patients do not have serious side effects or drug interactions, Unfortunately, some do experience side effects and must stop the medication(s). Common side effects include constipation, itching, nausea, vomiting, sedation or lightheadedness. Uncommon reactions include swelling in the legs, water on the lungs, trouble breathing (especially if you have emphysema/COPD or are on other narcotics), mental slowing and loss of coordination, lowering of sex drive, decreased testosterone (male sex hormone) and addiction. Note: pregnant women using opioids could make their newborn child dependent upon opioids. If you are pregnant, you need to alert your healthcare provider.
3. Dependence: Dependence is not the same as addiction. Many people who take opioids daily will become dependent on them. Dependence is when your body adapts to the medication and experiences withdrawal if the medication is stopped or lowered too quickly. Withdrawal symptoms include moodiness, aches and pains, sweating, diarrhea, abdominal pain and even seizures.
4. Addiction: Addiction is not the same as dependence. While many people become dependent on daily opioids, a percentage of these people will become addicted. Addiction is characterized by behaviors such as loss of control of drug use, compulsive use and craving and continued use despite harm or risk to the person. When people are addicted, they are not taking opioids simply to treat the pain.

Dr. Traina and his staff have explained the risks and benefits of opioid therapy for my pain.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.