Online Prescription Management Agreement

1. I will use one provider (or covering partner) to prescribe and monitor all opioid medications, benzodiazepine medications, and other pain medications.

2. I will keep (and be on time for) all my scheduled appointments with the provider and other members of the treatment team.

3. I will use one pharmacy to obtain all opioid prescriptions, benzodiazepine medications, and other pain medications prescribed by my provider.
Pharmacy: Phone Number:

4. I will inform my provider of all medications I am taking, including herbal remedies, since opioid medications can interact with over-the-counter medications and other prescribed medications, especially cough syrup that contains alcohol, codeine or hydrocodone.

5. I will be seen on a regular basis and given prescriptions for enough medication to last from appointment to appointment.

6. Prescriptions for pain medicine, or benzodiazepines or any other prescriptions will be done only during an office visit or during regular office hours. I will not call between appointments, or at night or on the weekends looking for refills. No refills of any medications will be done during the evening or on weekends.

7. I will not get any opioid pain medicines or other medicines that can be addictive such as benzodiazepines (Klonopin, Xanax, Valium) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekends.

8. I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.

9. I must bring back all pain medication and/or anti-anxiety medication prescribed by my provider in the original bottles. Pill counts may be conducted. These medications should be brought to all of my follow-up appointments with my provider.

10. I am responsible for keeping my pain medication in a safe and secure place, such as a locked cabinet or safe. I am expected to protect my medications from loss or theft. Stolen medications should be reported to the police and to my provider immediately. If my medications are lost, misplaced or stolen, my provider may choose to not replace the medications or to taper and discontinue the medications. If my medications are stolen, I will be required to bring the official police report to continue to receive those prescriptions.

11. If I require surgery, I must inform my prescribing provider in order to discuss the peri-operative need for pain management. Neglecting to do so may lead to termination of the provider/patient relationship and termination from the clinic.

12. I may not give or sell my medications to any other person under any circumstances. If I do, I may endanger that person’s health. It is also against the law.

13. Any evidence of drug hoarding, acquisition of any opioid medication or other pain medications from other providers (which includes emergency rooms), uncontrolled dose increases or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the provider/patient relationship.

14. I will communicate fully to my provider to the best of my ability at the initial and all follow-up visits my pain level and functional activity along with any side effects of the medications. This information allows the provider to adjust my treatment plan accordingly.

15. I will not use any illicit substances, such as cocaine, marijuana, etc. while taking these medications. This may result in a change to my treatment plan, including safe discontinuation of my opioid medications and benzodiazepine medications when applicable or complete termination of the provider/patient relationship.

16. The use of alcohol with opioid medications and benzodiazepine medications is contraindicated. The continued use of alcohol may lead to termination from the clinic.

17. I agree and understand that my provider reserves the right to perform random or unannounced urine and/or blood drug testing. If requested to provide a urine and/or blood sample, I agree to cooperate. If I decide not to provide a urine and/or blood sample, I understand that my provider may change my treatment plan, including safe discontinuation of my opioid medications and benzodiazepine medications when applicable or complete termination of the provider/patient relationship. The presence of a non-prescribed drug(s) or illicit drug(s) in the urine and/or blood can be grounds for termination of the provider/patient relationship. Urine and/or blood drug testing is not forensic testing, but is done for my benefit as a diagnostic tool and in accordance with certain legal and regulatory materials on the use of controlled substances to treat pain.

18. There are side effects with opioid therapy and benzodiazepine medications, which may include, but not exclusively, skin rash, constipation, sexual dysfunction, sleeping abnormalities, sleepiness, drowsiness, aggravation of depression, dry mouth, sweating, edema, nausea, vomiting, sedation, or the possibility of impaired cognitive (mental status) and/or motor ability. Overuse of opioids can cause decreased or slow respiration (breathing). You should also be aware of potential side effects such as decreased reaction time and clouded judgement, which could be a possible danger while operating heavy equipment or driving.

19. Physical dependence and/or tolerance can occur with the use of pain medications and/or anti-anxiety medications.

i) Physical dependence means that if the opioid medication is abruptly stopped or not taken as directed, a withdrawal symptom can occur. This is a normal physiological response. The withdrawal syndrome could include, but not exclusively, sweating, nervousness, abdominal cramps, diarrhea, goose bumps, runny nose, rapid heart rate, difficulty sleeping for several days, and alterations in one’s mood.
It should be noted that physical dependence does not equal addiction. One can be dependent on insulin to treat diabetes or dependent on prednisone (steroids) to treat asthma, but one is not addicted to the insulin or prednisone.
ii) Addiction is a primary, chronic neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestation. It is characterized by behavior that includes one or more of the following: impaired control over drug use, compulsive use, continued use despite harm and cravings. This means the drug decreases one’s quality of life.

iii) Tolerance means a state of adaptation in which exposure to the drug induces changes that result in diminution of one or more of the drug’s effects over time. The dose of the opioid may have to be titrated up or down to a dose that produces maximum function and a realistic decrease of the patient’s pain. This means you may need more and more drug to get the same effect.
20. If I have a history of alcohol or drug misuse/addiction, I must notify the provider of such history since the treatment with pain medications and/or anti-anxiety medications may increase the possibility of relapse. A history of addiction does not, in most instances, disqualify one for treatment of pain and/or anxiety, but starting or continuing a program for recovery is a must.

21. If I am pregnant or contemplating pregnancy, I will discuss with my provider.


22. I agree to allow my provider to contact any health care professional, family member, pharmacy, legal authority, or regulatory agency to obtain or provide information, including a copy of this agreement, about my care or actions if the provider feels it is necessary.
23. I agree to a family conference or a conference with a close friend or significant other if the provider feels it is necessary.

24. I understand that I may lose my right to treatment in this office if I break any part of this agreement. Should this happen, my provider will taper off the medicine over a period of several days to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended.