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: (501) 834 PAIN (7246) www.unitedpaincare.com : (866) 830 0939
PATIENT CONSENT FOR TREATMENT OF PAIN WITH CONTROLLED SUBSTANCES

CONTROLLED SUBSTANCES are drugs or chemical substances whose possession and use
are regulated under the Controlled Substances Act. These drugs have potential for abuse or diversion.Medications which bear the letter C together with Roman numerals II, III, IV are controlled substances. Strict accountability is necessary for their use. Controlled substances must be protected from animals, children and others.
UNDERSTAND YOUR OPIOIDS (also called narcotics) which are controlled substances used
for relief moderate to severe pain. Pain relief is an important medical reason to take opioids. HOW LONG DOES PAIN RELIEF FROM AN ORAL OPIOID LAST? Short-acting (immediate release) opioids usually have an effect for about 4 to 6 hours. These
include codeine (Tylenol #3®), hydrocodone (Vicodin®), hydromorphone (Dilaudid®), morphine (MSIR®), oxycodone (in Percocet®, Tylox®, or Roxicodone®), oxymorphone (Opana®), propoxyphene (in Darvocet-N® tablets). Short-acting opioids are usually taken when Some short-acting opioid medicines contain the opioid alone while others contain acetaminophen (Tylenol®). For example, oxycodone in combination with acetaminophen
(usually name ending with –cet) is Percocet®. The total dose of acetaminophen taken in one
day should not be more than 4000 mg. Higher doses could damage your liver. People who have liver disease or drink alcohol should take even less acetaminophen. Be aware of how much acetaminophen is in your prescribed and non-prescribed medicine, such as cold remedies.
Long-acting (controlled-release or extended-release) opioids are gradually released into the
body over an 8 to12 hour or longer period. These include morphine (Oramorph® , MS Contin® Kadian®, or Avinza®), oxycodone (OxyContin®) and oxymorphone (Opana ER®). They are taken at regularly scheduled times, such as every 12 hours. In addition, a short-acting pain medicine is sometimes prescribed as needed should the pain temporarily increase. Long- acting opioids are usually used for chronic pain that lasts most of the day. WHAT SHOULD I KNOW ABOUT OPIOIDS AND ADDICTION? There is a definite risk of addiction to these medications and a relapse occurring in a person
with a prior addiction. The extent of this risk is not certain. You or your family must understand addiction is a chronic brain disease that can occur in some people exposed to certain substances such as alcohol, cocaine, and opioids. Addiction would mean that your pain has gone away but you still “crave” for these medications for other reasons, such as unbearable emotional problems. Ask yourself: Would I want to take this medicine if my pain went away? If Addiction IS NOT when a person develops "withdrawal" (such as abdominal cramping or sweating) after the medicine is stopped quickly or the dose is reduced by a large amount. Your doctor will avoid stopping your medication suddenly. Addiction also IS NOT what happens when a higher dose after a period of time is needed in order to obtain pain relief. "Tolerance" to opioid medications does not affect everyone. 7481 Warden Road, Sherwood, AR 72120
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“Slowed breathing” is very rare when oral opioids are used appropriately for pain relief. If
you become so sleepy that you cannot make yourself stay awake, you may be in danger of slowed breathing. Stop taking your opioid and call 911 immediately.
Sexual Functions like mood, stamina, sexual desire and physical and sexual performance are
decreased with chronic opioid use. Low testosterone levels in men are known to occur. You MUST take advice from your obstetrician regarding use of controlled substances during pregnancy since the baby will become physically dependent upon opioids.
Constipation is very common. You will need to eat more fiber and drink more liquids than you
usually do. Many people also need to take a laxative which can be purchased without a prescription like Peri-Colace® capsules or syrup and Senokot-S® tablets. Ask your pharmacist
Nausea or vomiting does not always occur and usually settles after a few days. You can buy
nausea medicines like Dramamine® and Emetrol®. If your pain is under good control, you may be able to reduce the nausea by taking a lower dose of opioid.
Drowsiness (sleepiness) would be normal to some degree when you start taking an opioid,
but after a few days the drowsiness usually goes away. Beverages that contain caffeine, such as coffee or sodas may be helpful to offset drowsiness. If your pain is under good control, you may be able to reduce the drowsiness by taking a lower dose of opioid. If you feel drowsy, DO NOT drive or operate any dangerous machinery. Keep on top of your pain—don’t wait until pain becomes severe to take your medicine. Pain is easier to control before it reaches full force. Set a goal for pain relief that makes it easy for you to sleep at night and to do your daily activities. Take the next dose before the last dose wears off. If pain is present most of the day and night, the pain medicine may be taken at regularly scheduled times. If you are taking a short-acting opioid, this usually means taking it every 4 hours. You may need to set your alarm, especially at night, to be sure you take your dose before If you need to take more or less pain medicine than planned discuss this on your next appointment. If YOUR USUAL pain becomes so intense that you are unable to wait until your appointment, seek treatment by going to the nearest hospital emergency department or by calling 911. If you develop a new pain seek advice from your primary care doctor or hospital emergency departments. Don’t suddenly stop taking opioids without the knowledge of your Make a pain control diary to keep track on getting relief from your pain medication. Set a
goal for pain relief. Ask yourself what activities you need to be able to do with the use of pain medications. Then decide what pain rating will make it easy for you to carry out those activities. Everyone is different, but many people need a pain rating of 3 or less to be able to function well. If the pain medications do not improve your activity levels you may either need adjustments or tapering off because this would mean the pain is psychological and is not treatable with opioids in which case the medications are being used for addiction. Phone: (501) 834 PAIN (7246)
www.unitedpaincare.com
Fax: (866) 830 0939
The Poets 26:80: "And when I get sick, He heals me. YOUR CONSENT FOR CONTROLLED SUBSTANCE PRESCRIPTION
You MUST understand the above and agree with the policies in order to consent for the physician(s) from this practice to prescribe controlled substances to treat your pain. 1. All controlled substances must come from the physician(s) from this practice unless specific authorization is obtained for an exception. 2. All controlled substances must be obtained at the same pharmacy you select. You must get approval from our office BEFORE changing pharmacies. 3. The prescribing physician has permission to discuss all treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability. If it is discovered that controlled substances have been obtained from other sources, further treatment with controlled medications will be terminated. 4. Prescriptions and containers of these medications may be sought by other individuals with chemical dependency. You agree to take the highest possible degree of care with your medication and prescription. You may not share, sell, or otherwise permit others to have access to these medications. You assume entire responsibility of the consequences of diversion of these controlled substances which may include fines and/or imprisonment. This practice will not be held liable for the consequences of diverted controlled substances. 5. Since the drugs may be hazardous or lethal to another person, especially a child, you assume entire responsible for any such harm caused to others. 6. Treat your prescription like a check because of its value to you and others. Banks do not replace your lost or stolen money on cashed checks even with a police report. Medications CANNOT be replaced if they are lost, get wet, are destroyed, misplaced etc. There are NO EXCEPTIONS. Police reports are NO LONGER accepted for replacements. If you are UNABLE to protect your medications we are UNABLE to provide you controlled medications. 7. If the responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were obtaining medications at any unlisted pharmacy, all confidentiality is waived and these authorities may be given full access to our records of 8. If any prescription is found to be altered in any way, treatment with controlled substances from this practice will be discontinued with immediate effect and no responsibility will be assumed by this practice to treat withdrawal symptoms. On the sole discretion of the physician, all care from this practice may be terminated abruptly. 9. You must not alter the medications by breaking, crushing or extracting the medication by any means to take in any other form than is prescribed. 10. You agree for random urine or blood sampling. ABSENCE of prescribed substance will be reported to law enforcement agencies for investigation of diversion which may lead to imprisonment. PRESENCE of unauthorized substances may prompt referral for assessment for addictive disorder and discontinuation of treatment. Phone: (501) 834 PAIN (7246)
www.unitedpaincare.com
Fax: (866) 830 0939
The Poets 26:80: "And when I get sick, He heals me. 11. You CANNOT take alcohol in any form while taking controlled substances. Overdose and death is known to occur from interaction of controlled substances with alcohol. 12. It is NOT the policy of this practice to make medical decisions over the phone. No refills will be given over the phone. You are responsible during your appointment to remind the practice staff to ensure that you have sufficient refills until your next appointment. Original containers of medications should be brought in to each office visit for verification purposes. 13. Renewals are contingent on keeping scheduled appointments at the designated practice location. You cannot switch between practice locations on your own will. 14. Prescriptions will not be issued early if you have to go out of town when a refill is due. Arrangements can be made for mailing the prescription to a pharmacy of your destination. You are responsible to provide the correct pharmacy mailing address and phone number. This office will not be liable for loss or delay of prescription in the mail for any reason. 15. It should be understood that any medical treatment is contingent on evidence of benefit (e.g. activity levels). Prescription of controlled substances is to encourage “ability” to perform activities of daily living. The practice notes will not encourage applications made for “disability” on opioid medications. 16. You are expected to inform us of any new medications or medical conditions, and adverse effects. These drugs should not be stopped abruptly, as withdrawal may develop. 17. The risks and potential benefits of these therapies are explained above. You independently assume complete responsibility of all risks known and unknown associated with treatment of controlled substances and all your questions have been answered before you gave consent for treatment of your pain with controlled substances. 18. You affirm that you have read, understand, and accept all of its terms and that you have full right and power to sign and be bound by this consent. Furthermore, violation of any terms of this agreement on the sole discretion of treating physician will lead to discontinuation of treatment with controlled substances from this practice and automatically waive all confidentiality to share the information with any other medical practices. Your signature below acknowledges receipt of a copy of this document and understanding that you would be able to access the latest version on the practice website Pharmacy Selected: ____________________________________________________________________ Pharmacy Phone: __________________________ Patient Signature _____________________________ Date ________________ Patient Name (Printed) _______________________________________________ Witnessed by: _______________________________________________________ 1 This document is copyright. Use of the document is permissible at no charge with appropriate acknowledgment of United Pain Care. Phone: (501) 834 PAIN (7246)
www.unitedpaincare.com
Fax: (866) 830 0939
The Poets 26:80: "And when I get sick, He heals me.

Source: http://unitedpaincare.com/pdfs/Consent%20for%20Controlled%20Substance%20Prescription.pdf

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