Consent for Chronic Opioid Therapy

NC Pain Management Services, PA and its affiliates, is prescribing opioid medicine, sometimes called narcotic analgesics, to me for the treatment of "Chronic Pain". This decision was made because my condition is serious or other treatments have not helped my pain. I am aware that the use of such medicine has certain risks associated with it, including, but not limited to‑, addiction, overdose, death, sleepiness or drowsiness, constipation, nausea, itching, vomiting, dizziness, allergic reaction, slowing of breathing rate, slowing of reflexes or reaction time and possibility that the medicine will not provide complete pain relief. I am aware that some of these medications can be harmful and even lethal, when taken inappropriately. I am also aware that they can be lethal when ingested by a minor. Because of this, I agree to keep these medications under lock and key, in a safe place, away from the reach of everyone else, but me, even if I live alone.

I am aware that there are other types of invasive treatments that my doctor may want to try, in order to keep my pain and the use of these medications, to a minimum.

I will tell my doctor about all other medicines and treatments that I am receiving. I agree not to solicit or accept any other pain medication from any other source, other than this pain program, without the specific consent of my treating physician.

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: using heavy equipment or a motor vehicle, working in unprotected heights or being responsible for another individual who is unable to care for himself or herself.

I am aware that certain other medicines such as nalbuphine (NubainTM), pentazocine (Talwin TM), buprenorphine (Buprenex TM), and butorphanol (StadolTM), may reverse the action of the medicine I am using for pain control. Taking any of these other medicines while I am taking my pain medicines can cause symptoms like a bad flu, called a withdrawal syndrome. I agree not to take any of these medicines and to tell any other doctors that I am taking an opioid as my pain medicine and can't take any of the medicines listed above. I am aware that addiction is defined as the use of a medicine even if it causes harm, having cravings for a drug, feeling the need to use a drug and a decreased quality of life. I am aware that the chance of becoming addicted to my pain medicine is very low. I am aware that the development of addiction has been reported rarely in medical journals and is much more common in a person who has a family or personal history of addiction. I agree to tell my doctor my complete and honest personal drug history and that of my family to the best of my knowledge.

I understand that physical dependence is a normal, expected result of using these medicines for a long time. I understand that physical dependence is not the same as addiction. I am aware physical dependence means that if my pain medicine use is markedly decreased, stopped, or reversed by some of the agents mentioned above, I will experience a withdrawal syndrome. This means I may have any or all of the following: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, irritability, aches throughout my body and a flu‑like feeling. I am aware that opioid withdrawal is uncomfortable but not life threatening.

I am aware that tolerance to analgesia means that I may require more medicine to get the same amount of pain relief. I am aware that tolerance to analgesia does not seem to be a big problem for most patients with chronic pain, however, it has been seen and may occur to me. If it occurs, increasing doses may not always help and may cause unacceptable side effects. Tolerance or failure to respond well to opioids may cause my doctor to choose another form of treatment. I am aware and agree to follow my doctor's recommendations to go into a "Drug Holiday", as described in my orientation package. I am also aware and understand that failure to follow my doctor's orders will result in my discharge from the program. I also understand that if this occurs, my doctor will not be responsible for referring me to another program or doctor.

(Males only) I am aware that chronic opioid use has been associated with low testosterone levels in males. This may effect my mood, stamina, sexual desire and physical and sexual performance. I understand that my doctor may check my blood to see if my testosterone level is normal.

(Females Only) If I plan to become pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetric doctor and this office to inform them. I am aware that, should I carry a baby to delivery while taking these medicines, the baby will be physically dependent upon opioids. I am aware that the use of opioids is not generally associated with a risk of birth defects. However, birth defects can occur whether or not the mother is on medicines and there is always the possibility that my child will have a birth defect while I am taking an opioid.

I have read this form or have it read to me. I understand all of it. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. By signing this form voluntarily, I give my consent for the treatment of my pain with opioid pain medicines, and other medications commonly used in the treatment of pain.

Patient signature ___________________________________________________Ý Date ______________________

Witness to above ___________________________________________________Ý Date ______________________