Shared Responsibility Agreement PAIN

  • The following policies pertain to controlled substance medications. The goal of therapy is to improve functionality and comfort while keeping the dose and frequency as low as possible. Adverse effects that have been associated with controlled substances medications include addiction, relapse in patients’ prior addictions, physical dependence, respiratory depression, and death. The goal of this shared responsibility agreement is to make sure the medical provider and the patient are working together to have the best outcomes and keep the patient safe. I understand and will adhere to the following policies: 1. Prescriptions for all controlled substance medications must come from EMED Multispecialty Group only. If I receive a prescription for a controlled substance medication that is not from EMED Multispecialty Group, I must have written permission from EMED Multispecialty Group and on the new prescription from the other (new) physician that they are aware of and agree to knowing of each other writing controlled substance medications for me. 2. All prescriptions must be obtained from my pharmacy of choice. My pharmacy of choice is:
  • 3. I am aware of the pharmacist’s ability to view my entire controlled substance medications history from any pharmacy through the prescription drug monitoring program. If I decide to change pharmacies, EMED Multispecialty Group must be informed prior to changing. 4. I must inform EMED Multispecialty Group of any new medications and of any adverse effects I experienced from any medications I am currently taking prior to discontinuing them. I must not stop these medications abruptly or without consulting my provider due to the possibility of developing abstinence/withdrawal symptoms. 5. I am giving permission to EMED Multispecialty Group to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide my health care for purposes of maintaining accountability and coordinating my care. 6. I will participate in non-medical and no-opioid treatments, as my provider recommends, to help lower the risk of dependence and abuse in the forms of cognitive behavioral therapy, physical treatments, and non-opioid medications. 7. I may not share, sell, or otherwise permit others to have access to these medications. I must take all medications exactly as prescribed unless side effects develop. If a medication is prescribed “as needed”, I understand that I am not bound to taking it on a schedule (around the clock); however, taking the medication as signs and symptoms present throughout the day. I will not increase the dose or frequency of my controlled substance medications regimen, unless my provider has written a new prescription with revised directions. 8. I will not distribute my controlled prescriptions to anyone else. I acknowledge that these medications may be sought by people who have chemical dependency and that these medications need the highest degree of care. Controlled medications must be kept in secure/out of reach areas as they can be harmful/lethal to children and people who do not have a tolerance to their effects. I will not use illegal or street drugs, or other medications that were obtained illegally or that are meant for someone else. If I do, EMED Multispecialty Group has the right to discharge me from the practice. 9. I must bring original containers and remaining tablets, capsules, or liquid of controlled substance medications to each scheduled visit. 10. I understand that unannounced urine screenings may be requested and that my cooperation is required. Positive results for illegal drugs will result in immediate dismissal from EMED Multispecialty Group. Negative results for expected drugs will also result in immediate dismissal from EMED Multispecialty Group. PATIENT LABEL 11. I must exercise extreme caution when taking controlled substance medications and driving or operating heavy machinery. The use of these medications may cause drowsiness or impair mental abilities, thus making it unsafe to drive or operate heavy machinery. I am aware that these effects may occur particularly when the doses change, and I should refrain from activities if I am the slightest bit impaired. 12. I understand that alcohol use is prohibited when taking controlled substance medications. In no way should I be drinking alcohol on these medications as it could lead to adverse effects including death. 13. I must discuss the long-term use of controlled substance medications with my physician as it can lead to serious health risks. Controlled substance medications may cause addiction which can be harmful physically, mentally, and socially. I need to understand these risks. 14. I agree that these medications will not be replaced if they are “lost”. No excuse will be valid unless the medications have been stolen and a police report regarding the theft has been completed. Even then, the provider has the final say on replacing the prescription. 15. I understand that the prescriptions may be issued early only if I will be out of town when a refill is due. I must provide legitimate travel documents to provider for early refills to be possible. Even then, the provider has the final say on issuing the prescription. 16. I agree that, if the responsible legal authorities have questions concerning my treatment, all confidentiality is waived, and these authorities may be given full access to our records of controlled substance medications administration. If I have been or am arrested or convicted for a drug related offense, EMED Multispecialty Group has the right to dismiss me from the practice immediately. 17. I acknowledge that the risks and potential benefits of the therapy with controlled substance medications have been explained to me and that I have had the opportunity to ask any questions that I may have. 18. I can be dismissed from EMED Multispecialty Group if I display any aggressive behavior towards the staff. 19. Per EMED Multispecialty Group pain protocol, I shall receive Naloxone (opioid reversal agent) if I meet the following criteria: • Opioid and Benzodiazepine co-prescribing • Buprenorphine prescribing without Naloxone (for possible relapse) • Or patients who are receiving opioid dosages greater that or equal to 50 Morphine milliequivalents. Failure to adhering to these policies will be considered noncompliance and EMED Multispecialty Group can and may stop issuing all controlled substance medication prescriptions and possibly dismiss me from the practice all together. I have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication.
  • Date Format: MM slash DD slash YYYY