Controlled Substance agreement

The following agreement relates to my use of controlled substances including but not
limited to benzodiazepines, stimulants, sleep aides, and buprenorphine. I will be
provided with prescriptions only if I understand and agree to the following;

  1.  I understand that, depending on the drug and dose, I can become physically
    dependent on the medication and can develop withdrawal symptoms if
    medication is stopped suddenly or the dose is reduced rapidly. Although the risk
    is small there is a chance of developing an addiction to controlled substances.
  2. Controlled substances can cause sedation, confusion, or other changes in mental
    state and thinking abilities. I understand that the decision to drive while I am
    taking controlled substances is my own decision and i agree not to be involved in
    any activity that may be dangerous to me or someone else such as driving or
    operating any dangerous equipment, working in unprotected heights or being
    responsible for another individual who unable to care for his/herself if I am in any
    way sedated, feel drowsy or I am not thinking clearly.
  3.  I will not use any illegal controlled substances including, but not limited to
    marijuana and cocaine. I will not drive while intoxicated with alcohol.
  4. The office policy regarding the dispensing of controlled substances requires that
    I be seen regularly and I agree to make and keep my appointments. I will advise
    my doctor of all other medications and treatments that I am receiving. I consent to
    lab tests and routine monitoring as recommended by my clinician.
  5. If the medications require adjustment, an appointment must be made to see the
    Physician. No adjustments will be made over the telephone. My careful planning
    is required. I understand that medication refills and adjustments are only done
    during office appointments except under unusual circumstances. I must stay with
    the prescribed dosing so that I do not run out of medication early. The medication
    is expected to last until the GOOD UNTIL date that is found on the prescription
    bottle and/or package. I understand that the office policy is not to prescribe
    medications early, I may have to go without medication until my next prescription
    is due, possibly resulting in withdrawal symptoms.
  6. I understand that the prescriptions are my responsibility once they are placed in
    my hand and that if anything happens to my prescriptions (lost, stolen,
    accidentally destroyed) I may not receive a replacement prescription written from
    my physician. The office expects me to file a police report if my medication is
    stolen. I will be prepared to bring in a copy of a police report at my next office
    visit.
  7. Females Only- Because of the risk of certain medications to unborn children, I will
    inform all physicians immediately if I become pregnant or decide to try to become
    pregnant. I am aware that should I carry a baby to delivery while taking these
    medications, the baby may be physically dependent on these medications. I am
    aware that there is a risk of birth defects while on these medications. However,
    birth defects can occur whether or not the mother is on medication and there is
    always the possibility that my child will have a birth defect.
  8. I understand that in general I may be weaned off my medication or my drug
    therapy may be terminated at the discretion of my physician if any of the
    following occur:
    • It is the opinion of my physician that controlled substances are not very
      effective for my pain and or my functional activity is not approved,
    • I misuse the medication,
    • I develop a rapid tolerance or loss of effectiveness from my treatment,
    • I develop side effects that are significant and detrimental to me,
    • I obtain controlled substances from sources other than my psychiatrist
      without informing them,
    • I am arrested and/or convicted for a controlled or illicit drug violation
      including but not limited to drunk driving or driving while under the
      influence of a controlled substance,
    • Any violation of this agreement.