Controlled Substances

CONTROLLED SUBSTANCES CONTRACT 

 

Controlled Substances Contract 

(Benzodiazepines/Stimulants/Sedatives) 

 

The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. 

The long-term use of substances such as opioids (narcotic analgesics), benzodiazepine tranquilizers, barbiturate sedatives, and stimulants is controversial because of uncertainty regarding the extent to which they provide long-term benefits. There is also the risk of an addictive disorder developing or of relapse occurring in a person with a history of addiction. The extent of this risk is not certain. These drugs have the potential for abuse or diversion, and strict accountability is necessary when use is prolonged. For this reason, the following policies are agreed to by you, the patient, as consideration for, and on condition of, the willingness of the medical provider to consider the initial and/or continued prescription of controlled substances to treat your chronic condition. 

 

1. I understand an office visit every 4 to 8 weeks is required for the management of these medications. Medications prescribed will be typically given on a monthly basis. Failure to attend office visits will result in slow tapering and ultimate discontinuation of all controlled medications. 

 

2. I understand I must designate a single pharmacy at which to have all medications filled and will provide the doctor's office with the pharmacy phone number. 

 

3. I understand the medication prescribed will be by a single medical provider. This medical provider will be the only one to decide when and how these medications are changed. If the medical provider decides to discontinue the use of these medications the provider will follow me through the tapering off and I will agree to recommendations made by the medical provider. 

 

4. I understand the use of the medication is not to completely eliminate symptoms. Rather, the medication is used to significantly reduce symptoms so that I will be able to perform many activities of daily living as well as social activities. It is hoped that the use of these medications will improve the quality of life, but it is unexpected that complete symptomatic relief will ever be experienced with medication alone. 

 

5. I understand the use of this medication may result in physical dependence. This condition is common to many drugs including steroid and blood pressure medications. Physical dependency poses no problem to me as long as I avoid abrupt discontinuation of the drug. Medications can often be safely discontinued after slow tapering with your medical provider. 

 

6. I understand that addiction is a possible risk of the use of controlled substances. Addiction is recognized when the individual abuses the drug to obtain mental numbness or euphoria, when the patient shows a drug craving behavior, or engages in “Dr. shopping”, when the drug is quickly escalated without correlation with symptom relief, and when the patient shows a manipulative attitude towards the medical provider in order to obtain the drug. If I exhibit such behavior, the drug will be discontinued, and I will not be a candidate for continued controlled medications. 

 

7. I understand if I develop drowsiness, sedation, or dizziness I may not drive motor vehicles or operate machinery that can jeopardize my life or other people's lives. 

 

8. I understand the use of the medication is designed and prescribed only for me. I will never distribute it to others. 

 

9. I understand I may not stop taking medications abruptly. If this happens, withdrawal symptoms usually occur 24 to 48 hours after the last dose. In order to avoid the withdrawal symptoms, I must schedule my refill appointment prior to leaving the office. No refills will be done after office hours, or on the weekends. 

 

10. I understand I may not take other drugs such as tranquilizers, opiates, sedatives, or stimulants without first consulting with my medical provider. I may not use alcohol. I may not use marijuana medically or recreationally. The use of marijuana is against federal law and my medical providers ability to continue prescribing ongoing medications is licensed by the federal government- Drug Enforcement Agency (DEA). Marijuana is not endorsed by your medical provider secondary to unknown effects when used in combination with other medications and because it is against federal law. The combination of the above drugs and/or alcohol may produce symptoms that can lead to death 

 

11. I understand I must follow my medical provider's directions and not increase the dose of any of my medications on my own. Drug overdose can cause death. 

 

12. I understand I must take the medication as prescribed by my medical provider. Medications should be taken whole, they are not to be broken, chewed or crushed. Possible risk would be rapid absorption of the medication causing potential overdose and death. 

 

13. I understand if I am female, I should notify my medical provider if I am pregnant or at risk of possibly becoming pregnant. Children born when the mother is on certain controlled medications will likely be physically dependent on those medications at birth. 

 

14. I understand if there is any evidence of drug hoarding, acquisition of drugs from other medical providers, uncontrolled dose escalation, or other aberrant behavior, this would be followed by tapering and discontinuation of the medication, and possible discharge from the medical practice. 

 

15. I understand unannounced urine and/or blood serum toxicology screens may be requested and my cooperation is required. Presence of unauthorized substances may prompt referral for assessment for addictive disorder or discharge from the practice. 

 

16. I understand medications may not be replaced if they are lost, get wet, are destroyed, left on an airplane etc. If any medication has been stolen and I complete a police report regarding the theft an exception may be made. 

 

17. I understand early refills will not be given. 

 

18. I understand failure to adhere to these policies may result in cessation of therapy with controlled substances prescribing by this medical provider or referral for further specialty assessment. 

 

19. I understand any medical treatment is initially a trial and continued prescriptions are contingent on evidence of benefit. 

 

20. I understand that there is evidence in the current medical literature that certain conditions (Alzheimer's Disease, memory loss, and others) are associated with the prolonged use of controlled substances such as opiates, benzodiazepines and benzodiazepine-like medicines. Our medical advice is to minimize prolonged use of these medications and use alternative treatments if able. 

 

21. I understand that I will need to provide quarterly blood pressure, heart rate, height and weight measurements and that I may need to obtain specific equipment in order to do this. I also understand that I will need to provide annual physical results and basic blood work (CBC, CMP, triglycerides, cholesterol) from my primary care provider. If blood work was not obtained my psychiatric provider will send a request for this. If these conditions are not met controlled substances will not be prescribed. 

 

22. I understand that in future I may be required to meet with my psychiatric provider in person based on potential changes in the federal requirements for clients receiving controlled substances.