Download Controlled Substance Agreement

Controlled Substance Agreement
This agreement is a tool to protect you and your provider with guidelines based in the law, for correct controlled
substance use. This agreement tells how you can work with your provider to lower the risk of problems and
allow us to continue your care at our clinics.
Controlled substances, like narcotics, can have serious side effects. This is why they are legally called
“controlled substances.” Side effects include nausea, constipation, sleepiness, abnormal thoughts or dreams,
slowed reaction time, less sexual desire, allergic reaction, increased pain sensitivity, tolerance, physical
dependence, addiction, withdrawal and potential death from overdose. I understand that I have responsibilities
when I receive and use controlled substances. I accept these responsibilities and agree:
1. To actively participate in programs for improving my function and/or return to work.
2. To use my medications only at the dose and frequency prescribed.
3. To fill all controlled substance prescriptions at one pharmacy. This includes controlled substances other
than narcotics and prescriptions from any other provider (such as after surgery or from a psychiatrist).
4. To work with behavioral or mental health specialists, if recommended by my provider, so I can
understand how my chronic pain condition affects my mental and emotional health. I will work on my
mental and emotional health to lessen my pain and my need for pain medications.
5. To come to my scheduled appointments. If I need to cancel an appointment, I will give a minimum 24hour notice.
6. To consent to urine drug screens any time. I understand I may have to pay for them if my insurance
does not cover them. I have one hour within the clinic to give this urine.
7. To bring all of my medications (prescribed here or elsewhere; controlled substances only) to my visits
for pill counts, and to bring unused controlled substances here for disposal.
8. To keep and give a list of all my medications (including over the counter medicines, vitamins, herbal
products or medications prescribed by other providers) to all my providers.
9. To request a refill at least two FULL working days before I will run out of medicine IF I am not due for
an appointment yet. I understand that no clinic providers will prescribe controlled substances after
clinic hours, during weekends or on holidays.
10. To protect my prescriptions from loss, theft or accidental destruction. If my prescription is lost, stolen or
destroyed, I will write down what happened and give it to my provider. If my provider asks, I will also
get other written reports (such as police report) for my chart. I understand that I will not get
replacement or early refill prescriptions even if I do this.
11. To NOT operate heavy machinery or drive while taking controlled substances because they can make
me sleepy. I understand that I will get even sleepier if I take alcohol, some other drugs or some herbs. It
is my responsibility to keep others and myself from harm.
12. To not ask for narcotics or controlled substances from other providers. I will tell other providers of this
agreement and carry a copy of it to share with them. If I receive any controlled substances from them, I
will notify my provider here on the next clinic working day. I also take responsibility for getting copies
of all records from any emergency room, hospital, dentist, urgent care or specialist I see to my provider
here.
13. To agree to drug rehab or some form of addiction treatment program if my provider(s) think that I have
become addicted to any controlled substance or alcohol.
14. To allow my provider to talk about my pain management with other health care professionals and my
family members whenever medically necessary.
15. For women only: To talk with my provider if I plan to or become pregnant because controlled
substances may be especially harmful during pregnancy or while breastfeeding.
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My provider may reduce or immediately stop my controlled substance prescription if any one of the
following occurs:
 The provider feels that controlled substances are not helping to relieve my pain and
improve my ability to function.
 I develop side effects that worry my provider or me.
 I misuse the medications.
 I misuse alcohol or use other controlled substances not prescribed by my provider.
 I do not follow through with all parts of my treatment plan as listed below.
 I lose my prescription(s).
 I violate any other of the conditions of this agreement.
My provider WILL immediately stop my controlled substance prescription if any one of the following
occurs:
 I obtain narcotics or other controlled substances from other sources without promptly
notifying my provider here.
 I don’t cooperate when asked to give a urine specimen for drug screen.
 I have an abnormal drug screen (including lack of prescribed medication).
 I give away or sell my narcotics or other controlled substances.
 I behave fraudulently, like changing a prescription, using illegal substances, or
deliberately deceiving any health care professional to get medications. The clinic may
also be required to report fraudulent behaviors to law enforcement or other agencies.
I understand that stopping this controlled substance would just be a change in my treatment plan, based on
best clinical judgment, and would not represent abandonment or termination from this practice. I understand
that if one clinic provider stops this agreement that I cannot get a new controlled substance agreement from
another provider or clinic within this organization.
My Functional Goal(s): ______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
My Treatment Plan:
____Smoking Cessation
____Behavioral Health group
____Physical Therapy
____Individual counseling at ___________________________
____Occupational therapy
____Psychiatric treatment at ___________________________
____Home exercise/stretching
____Home relaxation/meditation/spiritual practice
____Acupuncture
____Manipulation/Chiropractic
____Massage therapy
____Natural Medicine consult
____Nutrition consult
____Weight loss (Goal weight _______)
____Vocational Rehab
____Specialist consult/manage _________________________
____Other (_________________________________________________________________________)
Controlled Substance(s), dose and frequency______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Provider______________________________
BH Provider___________________________
Patient name___________________________
Provider signature __________________________
BHC signature_____________________________
Patient signature____________________________
Pharmacy_____________________________
Visit frequency_____________________________
Date_______________D/C Date_______________
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