Opioid Agreement

  • Although controlled substance pain relievers are useful in the treatment of pain, they also have potential for misuse. Prescriptions are monitored by local, state and federal governments, as well as insurance companies and your pharmacy. In order for Colorado Clinic to prescribe controlled substance pain relievers or other controlled substances, we require you agree to the following conditions:

    1. Provide a complete and truthful medical, substance use and psychiatric history.
    2. Make sure past and current medical records from other providers are provided with my signed consent.
    3. Undergo reasonable diagnostic testing to evaluate my problem(s).
    4. Undergo consultation(s) including second opinions to evaluate and treat my problem(s).
    5. I will comply with the full treatment plan recommended to me, including physical therapy, injections, procedures and non-scheduled medications.
    6. Agree to urine, oral fluids, or blood testing as requested to confirm that I am taking my medication(s) as prescribed and not using illegal substances, marijuana or alcohol.
    7. The Colorado Prescription Drug Monitoring Program will be monitored regularly.
    8. I will only obtain controlled substance pain relievers from Colorado Clinic. I will not take controlled substance pain relievers from other medical providers, family members or friends.
    9. If controlled medications are obtained from an emergency prescriber for an urgent reason, I will ask that prescriber to send information to Colorado Clinic and in addition I will inform Colorado Clinic as well as follow subsequent recommendations made by Colorado Clinic the next business day.
    10. I will use my medications to treat my own pain. I will not share it with others, trade or sell my medications. 
    11. I agree to secure my medications so no else can use it or steal it. I will store unused medications in a combination lock box or locked cabinet. I will dispose of unused medications in a manner that is allowed by law. I will only carry essential, limited quantities of medication away from my home unless asked to do so by Colorado Clinic who may wish to examine them in office.
    12. I understand that if in spite of careful control, there is loss, destruction, or theft of medications then I will report that to Colorado Clinic on the next business day and obtain a police report of theft. Lost or stolen medications may not be replaced and additional medications may not be prescribed. 
    13. If I have side effects, I will decrease or discontinue the medication and notify Colorado Clinic.
    14. I will never increase the use of controlled medications without first consulting with Colorado Clinic. Dose adjustments often requirement appointments and may not be authorized via telephone.
    15. I will never use a medication in any way different from the way it is intended. I will not alter the physical properties of the medication by crushing, grinding, dissolving or extracting. I will not inject, smoke, snort, or inhale medications that are not intended to be used in these ways. 
    16. I will not use alcohol or products that have alcohol in them.
    17. I will not use marijuana or medical marijuana.
    18. I will not use illegal substances, such as cocaine, methamphetamine, amphetamine, etc.
    19. I will never write, call in, or change a prescription for myself or others.
    20. If I have been found to sell my medication, or forge or alter a prescription, or otherwise violate federal drug regulations, in addition to being discharged from the practice, I will be reported to the appropriate authorities.
    21. I understand office visits are monthly and at times more often, as needed and recommended. I understand that I am fully responsible for setting up my appointments. I am to be seen one week before running out of medication. Medications will not be called in after hours or on the weekends. 
    22. I will keep my scheduled appointments. Excessive rescheduling or missing appointments may result in discharge from the practice.
    23. Medications prescribed by Colorado Clinic will be brought to each appointment in their original packaging (bottle or box), as distributed from the pharmacy.
    24. Prescription refills require an appointment and must be picked up in person. Refills will not be given after hours, on weekends or holidays. Refills will not be treated as an emergency. Refills are typically only written for one month supplies. 
    25. Early refills will not be authorized.
    26. I will never pick up medication(s) at the pharmacy unless the full amount of that medication is available so that another prescription is not needed between office visits. If the pharmacy does not have the full amount, I will wait until the pharmacy has the full amount or go to another pharmacy.
    27. If the pharmacy cannot provide the full amount due to insurance restrictions, I will notify Colorado Clinic and follow any instructions that are given.
    28. If there is a delay at the pharmacy due to insurance prior authorization, I will wait for completion of that prior authorization. This emphasizes the importance of being seen for refills one (1) week prior to running out of medications. 
    29. If I become pregnant, I will notify Colorado Clinic immediately.
    30. If I am called for a pill count, I will bring all medications prescribed by Colorado Clinic in their original bottles into the office within 24 hours.
    31. I understand that if I do not provide a valid contact phone number at which I can be reached at any time during the day, I may be discharged from the practice.
    32. I will be respectful of all staff at the Colorado Clinic. This is not limited to scheduling office visits, arriving in a timely manner, calling the office for questions and/or concerns only during business hours excepting in emergency, reserving non-urgent questions and/or concerns for office visits.
    33. I will keep current with financial obligations to Colorado Clinic regardless of insurance coverage.
    34. I am aware some patients become addicted, develop tolerance or dependency while taking controlled substance medications. I agree to see an addictionologist if Colorado Clinic sees evidence of possible addiction. 
    35. I am advised that use/consumption of prescribed medications (scheduled or otherwise) may result in impairment and will not to drive or operate machinery while impaired.
    36. I understand I could be discharged from Colorado Clinic for reasons that include but are not limited to the following:
      1. Violation of the law
      2. Violation of this agreement
      3. Inappropriate, disruptive or dangerous behavior
      4. Refusal or inability to keep timely appointments or meet the financial obligations of this office
      5. Determination by Colorado Clinic they are no longer able to assist me.
  • 37. My pharmacy of choice is listed below:

  • I have read and agree to the above condition.