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CONTROLLED MEDICATION GUIDELINES
Opioids (narcotics) are used for the treatment of moderate to severe pain of acute (short-term) or chronic (long-term) origin. The use of narcotic pain medications in the treatment of chronic pain can be useful when other treatment therapies have failed. The long-term use of these medications can produce tolerance (need for higher doses) or physical/psychological dependence (need to continue medication to avoid withdrawal symptoms). The chronic use of tranquilizers and sedatives require similar respect. The provider and the patient each have responsibilities for the prescribing and the use of these medications.
Provider responsibilities:
- Complete a comprehensive medical history and physical exam prior to starting long-term pain or tranquilizer treatment, including information on past treatment and any history of drug addiction or abuse.
- Establish a diagnosis and medical indication for pain and/or anxiety treatment.
- Discuss with the patient the risks and benefits of long-term pain and/or anxiety treatment.
- Perform periodic reviews and modification of treatment if needed at least every 3-6 months.
- Provide consultation and referral to appropriate specialists and treatment centers as needed to evaluate and assist in the patient’s treatment.
Patient responsibilities:
- Use only one provider and one pharmacy to obtain controlled medications except in the case of emergency room treatment for an acute medical problem or if mutually agreed upon by another provider with this provider.
- All medical providers treating you will be made aware of controlled medication used and who is prescribing it.
- Medication will be taken only in the amount and frequency prescribed. No change in dosing should be made without first consulting the prescribing provider.
- The amount of medication given is for a specific period of time. No early refills allowed. Lost, stolen or destroyed medication may be replaced, but only once during a single calendar year. It is the patient’s responsibility to keep all medications in a safe place. Lost or stolen medication should be reported to the police. The misuse of medication may cause you to run out early resulting in unnecessary suffering and withdrawal.
- Refills will only be approved during normal office hours when the patient’s chart is available to review. Office hours: Monday through Friday, 8:30 am – 5 pm. You need to allow 48 hours for prescriptions.
- No alcohol or illegal drugs are to be used during the treatment with controlled medication.
- Periodic follow-up visits and review will be required for continued prescribing of controlled medication. Failure to keep appointments may result in discontinuation of treatment.
I have read and understand the above guidelines and have had all of my questions answered by the provider. I agree to comply with these guidelines. Any misuse of the controlled medication or failure to comply with the guidelines may be grounds for discontinuing the treatment.
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Patient name:______Patient signature:______Date:______