• INFORMED CONSENT FOR OPIOID TREATMENT

    Opioids (pain medications such as Morphine, Vicodin, Percocet, etc.) are very useful but have a potential for misuse and are therefore closely monitored and controlled by local, state, and federal governments. Because our providers prescribe such medication to help manage pain, we need you to read and follow these policies. Failure to abide by any of these conditions may result in the termination of the patient-physician relationship.

    You are responsible for your medications. By signing this Informed Consent, you agree to take the medication ONLY as prescribed and to contact us before making any changes.

    Increasing your medication without the close supervision of a physician could lead to drug overdose, severe sedation, respiratory distress, and/or death.

    Decreasing or stopping medication without the close supervision of a physician could cause withdrawal. Withdrawal symptoms include: yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, “goose bumps”, abdominal cramps, and diarrhea. These symptoms can occur 24-48 hours after the last dose and can last up to 3 weeks.

    Common side effects related to taking opioid medications include: vomiting, drowsiness, and constipation. Less common side effects are: mental slowing, flushing, sweating, itching, urinary difficulty, and jerkiness. Side effects may occur at the beginning of your treatment, and often will subside in a few days. It is your responsibility to notify the physician of any side effects that continue or that are severe.

    Notify our office immediately if you go to the emergency room or see another physician for pain, or if you become pregnant.

    Prescription medications are for the use of the person whose name appears on the label only. Prescription medication should NEVER be given to others. If children are in the house, child-proof lids are required on all medication bottles.

    Contact our office before taking ANY other medication (prescription or over-the-counter) or herbal supplements. Combining opioids and benzodiazepines, sedatives, anti-histamines, and some herbal supplements may produce profound sedation, respiratory depression, severe drop in blood pressure, and death.

    You should not use alcohol or other recreational drugs while taking prescribed opioids.

    You are responsible for your medication. Opioid prescription(s):

    • Can only be written for a one month supply.
    • Will always be filled at the same pharmacy (your choice, listed on this Informed Consent).
    • Will be filled only with an appointment during regular office hours Monday through Friday.
    • Can be picked up in person only.
    • Refills will NOT be given after hours, on weekends, or holidays.
    • Will NOT be replaced if the prescription is lost, spilled, or misplaced.
    • Will be taken only as prescribed by my physician.
    • Refills will not be treated as an emergency. You are responsible for keeping track of when you will run out. Please call at least one week before you run out to make an appointment for refills.
    • If your medication is stolen, report it to the police department and obtain a stolen item report. Replacement prescriptions may be given at the sole discretion of the physician, and only with appropriate documentation.
    • If you use a mail order pharmacy, you MUST send your prescriptions by certified mail. We cannot be held responsible for the pharmacies timeliness or for the delivery by the US post office, or any other delivery service. You can always fill your prescriptions at a local pharmacy. Replacement prescriptions may be given at the sole discretion of the physician, and only with appropriate documentation.

    While physical dependence is to be expected after long-term use of opioids, signs of addiction will be interpreted as a need for weaning and detoxification.

    • Addiction is a psychological and behavioral syndrome that is recognized when the patient shows drug “craving”, doctor or pharmacy “shopping”, manipulation of a doctor or pharmacy to obtain drugs, or abuse of medication to get a “high”. Patients that show signs of addiction are not good candidates for the opioid trial.
    • If you begin to exhibit such behaviors, your medications will be tapered and stopped.
    • Patients that display manipulative or illegal behaviors to obtain medications may be discharged from the practice.

    The physician’s treatment plan may include a time contingent use of opioids. If it appears to the doctor that there is no improvement in your quality of life or daily functioning, then the opioids may be discontinued.

    By signing this Informed Consent, you agree:

    • To submit to drug screen testing as determined by the physician.
    • That if you do not follow the conditions stated in this document, we will discontinue your opioid medications.
    • To make an appointment to have any questions or concerns about this Informed Consent or your treatment addressed before a problem arises.
    • That you are not being investigated, charged, or convicted of federal controlled substances laws.
    I authorize the release of information by the physicians and designees of Colorado Clinic to my other health care providers, my pharmacy, and my insurance company or other reimbursing agencies as designated.
  • , have read the above Opioid Informed Consent, or have had it read to me. I have received a copy of this document, and have had all of my questions and concerns addressed to my satisfaction.

  • I hereby give my consent to participate in opioid medication therapy.