Maryland Pain Specialists, P.A.
410 825-6945

INFORMED CONSENT & OPIOID TREATMENT AGREEMENT

I.  Purpose of Opioid Therapy
I have agreed to use opioids (morphine-like drugs) as part of my treatment for chronic pain.  In general, opioids can be used safely and effectively for pain control, however, I understand that these drugs have a high potential for misuse and carry the risk of addiction. These drugs are therefore closely controlled by the local, state, and federal government. This agreement is a tool to establish guidelines within the laws for proper controlled substance use.
 

II.  Potential effects of Opioid Therapy

Sleepiness or Slow thinking	Itching, Sweating
Mental confusion, bad dreams, or hallucinations	Nausea or vomiting
Decreased sex hormones	Depression
Irregular or no menstrual periods	Dry mouth that causes tooth decay
Constipation or in rare cases, intestinal blockage	Allergies

Other risks of opioid therapy: 

 

Sleep apnea (abnormal breathing pauses during sleep)	Worsening of pain
Impaired driving or impaired ability to safely operate machinery	Death
Withdrawal symptoms if you suddenly stop taking opioids, lower the dose of your opioids too quickly, or take a drug that reverses the effects of your opioids. Withdrawal symptoms are caused by a physical dependence that is a normal result of long-term opioid therapy. Some common withdrawal symptoms are: runny nose, chills, body aches, diarrhea, sweating, nervousness, nausea, vomiting, mental distress, and trouble sleeping
Increased tolerance. You may need a higher dose of opioid to get the same pain relief, resulting in an increase in the likelihood of the other side effects and risks.
Addiction (craving for a substance that gets out of control). Some patients become addicted to opioids even when they take opioids as prescribed.
Drug interactions (problems when drugs are taken together). Taking small amounts of alcohol, some over-the counter medications, some herbal remedies, and other prescription medications can increase the chance of opioid side effects.
Risks in pregnancy: Continued use of opioids during pregnancy can cause your baby to have withdrawal symptoms after birth and require your baby to stay in the hospital longer after birth. Stopping opioids suddenly if you are pregnant and physically dependent on opioids can lead to complications during pregnancy. Studies have not shown a clear risk for birth defects with opioid use in pregnancy. If there is an increased risk for birth defects in pregnancy with opioid use, it is likely small.

III. Alternatives to the treatment 
You have the option not to take opioids. Other treatments can be used as part of your pain care plan. Not all alternative therapies are appropriate for all patients. Ask your provider what alternative therapy is appropriate for you. Alternatives include: 

 

Rehabilitation	Weight Loss
Stretching, Exercise	Relaxation or stress reduction training
Nerve Stimulation	Counseling & coaching
Self-care techniques	Specialist pain care
Injections	Surgery
Heat & cold therapy (heating pads, ice packs)	Meditation
Chiropractic	Physical Therapy
Mental health treatment	Massage
Support groups	Acupuncture
Attention to proper sleep	Non-opioid pain medicines (Non-steroidal anti-inflammatory  drugs, antidepressants, anticonvulsants)
Pain classes	Occupational Therapy

 

IV. Patient responsibilities

      Because my health care provider is prescribing such medication to help manage my pain, I agree to the following conditions: 

1.  I will not increase the dose or frequency of any prescribed medication without the direction of the provider.   

1. a. I understand that increasing my dose without the consent and supervision of my provider could lead to drug overdose causing severe sedation, respiratory depression, and even death. Increasing the amount of medication taken over the prescribed dose and frequency can also result in discontinuing this treatment by my provider. 

2. b. I understand that decreasing or stopping my medication will not violate this agreement, but doing so without the supervision of my provider can lead to withdrawal.  Withdrawal symptoms include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, “goose flesh”, abdominal cramps and diarrhea.  These symptoms can occur 24-48 hours after the last dose and can last up to 3 weeks. 

2.  Unless specific authorization is obtained for an exception, I will not request or accept controlled substance medications from any other physician or individual while I am receiving such medication from my physician at Maryland Pain Specialists.  I will inform my primary care physician of my use of prescribed opioids. 

3.  I understand that the opioid medication is strictly for my own use.  The medication should never be given to others. 

 

4.  I understand I must contact my pain provider before taking other controlled drugs.  Medications like Valium or Ativan, sedatives such as Soma, Xanax, Fiorinal, and antihistamines like Benadryl, may produce profound sedation, respiratory depression, blood pressure drop, and even death when taken with opioids. 

 

5.  I will not use, purchase, or otherwise obtain any illegal drugs including marijuana, cocaine, etc. Opioid medications may be expected to have additive effects when used in conjunction with alcohol or illicit drugs that cause central nervous system depression. 

 

6.  I agree to return to the office at least once a month or whenever instructed by my provider for medical evaluation. 

7.  I understand that opioid prescriptions will not be mailed.  I will pick up my refill prescriptions at my visit in the office with my pain provider.  If I am unable to obtain my prescriptions monthly, I will be responsible for finding a nearby physician who can take over the writing of my prescriptions. 


8.  I am responsible for my opioid prescriptions and medications.  I understand that:
9.   I will familiarize myself with the State of Maryland Department of Health and Mental Hygiene (DHMH) recommendations regarding the use of Naloxone for patients at risk of an opioid overdose and the DHMH Overdose Response Program. I understand that I may be required to obtain Naloxone. Failure to do so may be considered a violation of this agreement

10.  I will not be involved in any activity that may be dangerous to me or someone else if I feel drowsy or am not thinking clearly. I am aware that even if I do not notice it, my reflexes and reaction time might still be slowed. Such activities include, but are not limited to: operating heavy equipment or driving a motor vehicle, working at unprotected heights or being responsible for another individual who is unable to care for himself or herself. Please consult all applicable laws regarding DUI (Driving under the influence) and any other occupational restrictions. If there is any concern regarding ability to drive safely while taking any medication it is strongly recommended that the Motor Vehicle Administration test be repeated.

V. Reasons for Opioid Discontinuation 

 

1.   If it appears to my provider that there is no improvement in my pain, daily function, or quality of life from the controlled substance, my opioids may be switched, reduced, or discontinued.  

 

2.   I agree to submit to urine, saliva, and blood screens at any time as determined by my physician to detect the use of both prescribed and non-prescribed medications along with alcohol use. This must be done on the day that it is requested. Refusal would likely result in discontinuation of my treatment with controlled drugs. 

 

3.  I understand that any single violation of the above conditions may result in termination of my opioid medications.  I will then be offered other therapies and/or I may be discharged from treatment by Maryland Pain Specialists. 

 

4.  I authorize any pharmacy or treating physician to release information regarding my prescription drug treatment to my pain provider.   I authorize my pain specialist to speak with any licensed healthcare provider involved in my treatment about my condition and drug use.  

 

5.  I authorize full disclosure of any prescription or medication related information from any pharmacy to my medical care team at Maryland Pain Specialists. 

 

I have read the above information or it has been read to me and all of my questions regarding the treatment of pain with opioids have been answered to my satisfaction.  By signing this form voluntarily, I understand and accept all of the terms listed above regarding the treatment of my pain with opioid medications.

 

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