Informed Consent Controlled Substance Agreement

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The purpose of this agreement is to create an understanding regarding controlled substances that may benefit your chronic pain symptoms. My goal is to treat you safely with these potent medications and to prevent abuse of or addiction to these medications. Medications such as opioids, benzodiazepines, tranquilizers, barbiturate sedatives, and muscle relaxants, that may be useful in managing pain, can be problematic in several ways. Many of the medications used have common side effects such as dizziness or drowsiness, dry mouth, constipation, nausea, itching, fatigue, vomiting, headache, insomnia, sweating, nervousness, confusion, falls, anxiety, edema/swelling, urinary retention, and sexual dysfunction. These medications have "street value" and potential for abuse. Although these medications may be prescribed with a goal of improving your comfort and functionality, their medical use is also associated with the risk of serious adverse effects such as development of addiction disorder or relapse in a person with prior addiction history. The extent of this risk is uncertain, but it is known to be higher in certain vulnerable patients. My goal is to have you take the lowest possible dose of medication that is reasonably effective in managing your pain and improving your function, and when possible, have it tapered and eventually discontinued, while at the same time monitoring and managing these potential risks.

understand and voluntarily agree that (initial each statement after reviewing):

I understand that there may be instances where a medication is not available at my chosen pharmacy and that should this happen, I will call the office and let the staff know of the pharmacy change.

I have been told that:

  1. If I drink alcohol or use street drugs, I may not be able to think clearly, and I could become sleepy and risk personal injury or injury to others. I may even die.
  2. I may get addicted to this medicine.
  3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.
  4. If I need to stop this medicine, I must do it slowly or I may get very sick.

If you become addicted to these medications, we will help you get treatment and get off of the medications that are causing you problems safely, without getting sick.

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.

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