Substance Abuse Educational Material

and Controlled Substance Patient-Physician Agreement

 

PURPOSE

 

The purpose of this document and educational material is to:

1.       Clearly and unequivocally state the Pain Programís opposition to prescription drug misuse, abuse, unlawful possession, distribution, or use of illegal drugs and/or alcohol, by our clients (patients).

2.       To ensure that our patients are aware of the health risks associated with, as well the destructive and devastating impact of the abuse of prescription drugs, use of illegal drugs, and/or alcohol.

3.       To clearly state the disciplinary sanctions that the Pain Program may impose on those patients who violate the understandings and agreements of this document, as well as the standards of conduct.

4.       To encourage early identification of substance abuse and to advocate self-referral for treatment and rehabilitation.

5.       To ensure that all patients are aware of the applicable local, state and federal sanctions pertaining to the illegal possession, distribution and use of controlled substances and alcohol.

6.       To inform patients on the ìNorth Carolina Board of Medical Examinersî requirements for the prescription of addictive or dependence producing drugs (controlled substances).

7.       And to serve as an informed consent for the use of these medications.

 

DEFINITIONS

 

- The term ìsubstance abuseî as used in this agreement is defined as:

  1. Use, usually by self-administration, of any drug in a manner that deviates from the approved medical or social patterns.
  2. Use, usually by self-administration, of any drug in a manner other than medically prescribed.
  3. Chemical dependency on alcohol or other drugs where job performance, participation in social events, or performance of daily activities may be adversely affected.
  4. Unlawful possession, distribution, selling, purchasing, and/or use of drugs.
  5. The use of illegal drugs.

 

- The term ìillegal drugsî as used in this agreement includes, but is not limited to:

  1. Marijuana, cocaine, heroin, opiates, amphetamines, benzodiazepines, and similar drugs whose possession and use are prohibited under state and federal law.
  2. Prescription drugs, unless taken as prescribed by your physician.
  3. îDesigner drugsî, ìlook alikeî, synthetic drugs, and similar substances.
  4. Controlled substances (See Appendix I) used in any manner other than prescribed.

 

- Federal Law defines the term ìaddictî as:

 

ìAny individual who habitually uses any controlled substance so as to endanger the public morals, health, safety, or welfare, or who is so far addicted to the use of the drug(s) as to have lost the power of self-control with reference to his addiction.î

 

- The term ìphysiological dependenceî is defined as:

 

The physiologic phenomenon by which a patient, regularly taking a narcotic, develops physical dependence to the drug, as evidenced by the development of withdrawal symptoms upon stopping the medication. Not to be confused with addiction, which requires a psychological dependence on the substance, with an irrational fear to stopping the medicine.

 

- Federal Law defines ìIntractable Painî as:

 

ìA pain state in which the cause of the pain cannot be removed or otherwise treated, and for which in the generally accepted course of medical practice no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts.î

 

- The term ìtoleranceî as used in this agreement is defined as:

 

The physiologic phenomenon by which a patient develops resistance to the effects of pain medications such as narcotics. This is a problem that develops at the level of the opioid receptors in your body and therefore, cannot be solved by switching to another narcotic, since most of them work at the same receptors.

 

- The term ìcross-toleranceî as used in this agreement is defined as:

 

The physiologic phenomenon by which a patient taking one type of narcotic develops tolerance to other types never used before. It is a well-known fact that when a patient develops tolerance to a narcotic, he/she will also have developed tolerance to all narcotics. This is known as ìcross toleranceî.

 

- The term ìDrug Holidayî is defined as:

 

The period during which the medications are stopped. Drug Holidays should be tailored to the pharmacokinetics of the medication for which it is intended. (e.i. in the above mentioned example for morphine, they should be 7 to 10 days in duration while in the case of methadone, they should be 3 weeks in duration.) During the Drug Holidays, clonidine can be administered for one week, to help with the hyperactivity of the sympathetic autonomic nervous system. This medicine will lessen the withdrawals, but will not completely get rid of them. During the Drug Holidays, because of cross-tolerance, patients should not be allowed to switch to another opioid. When returning to the opioid, at the end of the Drug Holiday, the patient should always be started at a lower dose than the dose prior to the Drug Holiday. They should be repeated as often as necessary to allow the patient to control his/her medication intake, rather than allowing the medication to control the patient. On the average, patients are asked to take Drug Holidays of 14 days in duration. For more information, click here.

 

 

HEALTH RISKS

 

The following is a summery of the various health risks associated with the use and abuse of some specific types of substances; it is not intended to be an exhaustive or final statement of all possible health consequences of substance abuse. A more extensive description on health risks related to abuse of controlled substances may be found in medical text books related to this subject.

 

Alcohol use and Abuse. Alcohol is the most widely used and abused drug in the United States. Alcohol consumption has both acute and chronic effects on the body and causes a variety of changes in behavior. Even low doses significantly impair the judgment and coordination required to safely drive a car, increasing the likelihood that the driver will be involved in an accident. Low to moderate dosage of alcohol is associated with a variety of aggressive acts, including spouse and child abuse and dangerous risk-taking behavior. Moderate to high doses of alcohol may cause marked impairment of higher mental functions such as severely altering a personís ability to learn and remember information. Very high doses may cause respiratory depression and death. If combined with other depressant type drugs, much lower doses of alcohol can be fatal.

 

Alcohol-related automobile accidents are the number one cause of death among people ages 15 through 24 and is involved in 50% of all fatal traffic accidents. Furthermore, approximately 50% of all deaths from drowning, fires, suicide and homicide are alcohol-related.

 

Repeated use of alcohol can lead to physical and psychological dependence. Alcohol dependent persons who suddenly stop drinking are likely to suffer withdrawal symptoms, including severe anxiety, tremors, hallucinations, confusion, convulsions and can be life-threatening. Long-term consumption of large quantities of alcohol, particularly when combined with poor nutrition, can lead to permanent damage to vital organs such as the brain, heart and liver. Women who drink alcohol during pregnancy may give birth to infants with serious birth defects, including fetal alcohol syndrome. These infants may have irreversible physical abnormalities and mental retardation. In addition, research indicates that children of alcoholic parents have an increased risk of becoming alcoholics themselves.

 

Drug Use and Abuse. Controlled substances can be as detrimental and dangerous to your health as alcohol. The use of medically prescribed opioid analgesics for the relief of pain is quite proper; however, the self-administration of the same drug, in the same dosages, for relief of depression or tension or to induce euphoria is considered flagrant abuse. One of the hazards in the use of drugs to alter mood and feeling is that individuals eventually develop a dependence on the drug. They continue to take it in the absence of medical indications, often despite adverse social and medical consequences, and they behave as if the effects of the drugs are needed for continued well-being. For more information, click here.

 

Interactions. Central Nervous System and circulatory depressant effects of narcotics can be potentiated by alcohol, sedatives, other narcotics, antihistamines, barbiturates, benzodiazepines, phenothiazines, butyrophenones, MAO inhibitors, and tricyclic antidepressants.

 

Overdose Sleepiness and drowsiness, slow breathing with progression to respiratory depression and apnea (complete cessation of breathing drive).

 

Toxicity. Somnolence, coma, respiratory arrest, apnea (to stop breathing), cardiac arrhythmias, combined respiratory and metabolic acidosis, circulatory collapse, cardiac arrest, and death.

 

Principal Adverse Reactions and Side Effects. Hypotension(low blood pressure),hypertension(high blood pressure),bradycardia(slow heart rate), arrhythmias, chest wall rigidity, bronchospasm, laryngospasm, blurred vision, syncope, euphoria, dysphoria, urinary retention(inability to void), antidiuretic effect, ureteral spasm, biliary tract spasm, constipation, anorexia, nausea, vomiting, delayed gastric emptying, miosis, pruritus(itching), urticaria.

 

Scope

 

  • Unless a standard of conduct is specifically limited to a particular group, the standards apply to all patients.
  • This agreement is not intended to affect the Pain Programís right to manage our patients individually, nor does it guarantee a permanent patient-physician relationship. We reserve the right to modify our policies from time to time as the Pain Program deems appropriate.

 

Patient Responsibilities

 

The patient agrees:

1)       To provide the physicians with accurate and complete information about his/her symptoms, medication use, and any other conditions or events that may be related to the pain or medication management.

2)       To have a primary care physician, with the understanding that once an adequate medical regiment has been established by the Pain Program, this physician may assume the responsibility of prescribing the controlled substances.

3)       To keep all scheduled appointments at the Pain Program.  If the patient is unable to keep an appointment, they must give at least a 24-hour advance notice.

4)       To keep and attend his/her appointments in a timely manner.

5)       To provide the program with the name, address and telephone number of his/her pharmacy of choice.

6)       To have his/her prescriptions filled at one pharmacy only.

7)       To provide written notice when changing pharmacy.

8)       In the event of an emergency requiring another physicianís attention, the patient or his/her family will inform the pain physician of the event. If this emergency is in any way related to the medications or treatment received from our pain program, the notification should be immediate.

9)       To allow the pain physician to send a copy of this agreement to the patientís pharmacy, referring physician and any other physician involved in his/her care.

10)   To allow the pain physician to freely discuss his/her case with any other physician involved in his/her care.

11)   To take the medication only as prescribed.

12)   Not to share medications with other individuals.

13)   To maintain the controlled substances under lock and key, to prevent minors or other persons from having access to them.

14)   The patient understands that these medications can be addictive, will cause physiologic dependence, and have the potential to be lethal.

15)   The patient understands that prescribed controlled substances shall not be shared or used by anybody else, except the patient for whom the medication was prescribed.

16)   The patient understands that NO early refills will be provided if the prescription does not last because of misuse.

17)   The patient understands that NO lost or stolen prescription or medications will be replaced until it is time for the next refill.

18)   The patient understands that a Police report will not be considered as acceptable proof of theft or loss.

19)   The patient understands that he/she is responsible for the security and care of his/her medications.

20)   The patient understands that if a mail-ordered medication is lost in the mail, it will not be refilled and that no ìU.S. Postal Service Mail loss/rifling reportî will be accepted as proof.

21)   The patient understands that prescriptions will be written only at scheduled office appointments.

22)   The patient understands that NO prescriptions will be faxed or called-in.

23)   The patient understands that NO medications will be refilled, changed, or new medication started over the phone.

24)   The patient understands that prescriptions shall not be given to anybody else, except for the patient.

25)   The patient understands that nobody will be allowed to pickup prescriptions without an appointment. Not for themselves, not for family members, not for relatives, and certainly not for friends.

26)   The patient agrees not to seek pain medication at night, on weekends, holidays, or prior to their next appointment.

27)   The patient agrees not to request pain medication from any other physician or emergency room. Specifically, the patient will not ask the referring physician (the physician that sent you to the clinic) for any pain medication.

28)   The patient understands that obtaining controlled substances, specifically narcotics and other pain medications, from more than one physician is strictly prohibited. This is termed ìDoctor Shoppingî and it is illegal in North Carolina.

29)   The patient agrees to follow the pain physician recommendations with regards to medication use and selection.

30)   The patient agrees to follow the advice of the physician if told to stop the use of a medication.

31)   The patient agrees to have the Pain Program do random drug testing and call other pharmacies to check prescriptions and/or usage of medications. New patients are required to undergo a mandatory drug screening test.

32)   The patient accepts that from time to time, prescribed medication may be changed at the physicianís discretion.

33)   The patient understands that he/she is prohibited from driving, operating heavy machinery, or handling firearms or other weapons while under the influence of controlled substances.

34)   The patient understands that the sale, distribution, manufacturing, possession, or use of illegal drugs, or drug paraphernalia is prohibited and may result in termination of treatment and dismissal from the Pain Program.

35)   The patient understands that violation of any of the laws provided in will result in termination of treatment and dismissal from the Pain Program.

36)   The patient understands that attempted suicide or suicidal ideations will require the patient to maintain psychiatric counseling and may result in immediate discontinuation of all medications that may be misused for this purpose. (This would include all pain medications)

37)   The patient understands that all controlled substances prescribed, which are later found not to be useful in the treatment of the patientís condition, or have caused side effects rendering them useless, shall be returned to the pain program for documentation on their disposal. Individuals, who fail to return the unused portion of the prescription, will not receive any additional controlled substances until the due time for the next refill date is reached.

38)   The patient understands that in order to generate adequate proof, medications should only be discarded at the Pain Programís facilities, in the presence of witnesses. The patient also understands that videotapes will not be accepted as proof of disposal.

39)   The patient understands that he/she is required to bring all prescribed controlled substances to each appointment for inspection and accountability.

40)   The patient understands that it is the patientís responsibility to keep track of their medications, and to remind their pain physician to write the prescription during the appointment.

41)   The patient understands that for their own safety, they should not volunteer information about their medications to any non-medical personnel, with the exception of officers of the law. This is especially true for other ìpatientsî wanting to inquire about your medications. (Be aware that there may be people running drug schemes out of ìDoctorís Waiting Roomsî. Do not volunteer: what you take; how you take it; or where and when you buy it.)

42)   The patient agrees to destroy the medication labels before discarding the empty medication vials.

43)   The patient understands that the pain physician will modify treatment if any of the following occurs:

a)       The patient develops rapid tolerance or loss of effect to pain medication.

b)       The patient develops side effects from the pain medication.

c)       The patientís functional activity level decreases.

d)       The patient develops a habitual use that endangers the public morals, health, safety, or welfare.

e)       The patient develops addiction to the use of drugs to the point of loss of self-control over the addiction.

44)   The patient understands that the pain physician may terminate treatment if any of the following occur:

a)       The patient shares, sells, or misuses the pain medication.

b)       The patient fails to keep three(3) scheduled appointments.

c)       The patient attempts to obtain pain medication at night, on weekends, on holidays, sooner than the next office visit, from any other physician, from an emergency room, or from any other source.

d)       Attempts to commit suicide.

e)       The patient engages in activities which may endanger their lives, or that of others. (e.i. Driving a motor vehicle, or handling any weapons while using narcotics)

f)         The patient engages in the use of illegal drugs, or the use of alcohol in conjunction with the prescription drugs.

45)   The patient agrees to adhere to the advice of the physician regarding operation of motor vehicles.  If the Pain Program witnesses or is able to validate information of the patient driving under the influence (i.e., drugs or alcohol), the patient authorizes the Pain Program to notify the authorities and not be held liable for any damages which may occur.

Conditions

 

To receive narcotic pain medication, the patient must meet the following conditions:

  1. The patient has never been diagnosed with, treated or arrested for substance dependence or abuse.

2.       The patient has never been involved in the sale, illegal possession, dispersion or transport of controlled substances (narcotics, sleeping pills, nerve pills, pain pills). (See Appendix I)

3.       The female patients certify that they are not pregnant.  The patient certifies that she will notify the Pain Program if she is planning a pregnancy, or believes that she may be pregnant.

  1. The patient must have an identifiable organic basis for the pain.

 

STANDARDS OF CONDUCT

 

  • As a condition to maintain a patient-physician relationship, each patient of the Pain Program is required to comply with the terms of this policy.
  • Continuity of a patient-physician relationship is contingent on the successful completion and results of a drug-screening test.
  • The patient will be required to maintain counseling with a psychologist or a psychiatrist, on a regular basis, for the purpose of monitoring and treating any possible abuse potential.
  • The patient agrees to have his/her name, address, and telephone number submitted to authorities such as the Police, SBI (State Bureau of Investigations), and the Board of Medical Examiners of the State of North Carolina, in order for these governing bodies to maintain a database of patients who have access to controlled substances.
  • The patient will be required to schedule a family conference during one of the initial appointments for the purpose of informing the family of the relative risks of dependency or addiction and what they mean to the patient and to the patientís family.
  • The patient is required to take ìDrug Holidaysî as often as necessary to keep the tolerance to the medications down.
  • The Pain Program reserves the right to enforce ìDrug Holidaysî whenever it becomes necessary, especially if the patient does not voluntarily proceeds with them.
  • The Pain Program reserves the right to subcontract a private investigator for the purpose of surveillance of those patients suspected of substance abuse.
  • The patient is required to notify the Pain Program whenever a physician, who is not part of the Pain Program staff, recommends, orders, or prescribes more pain medication, a different pain medication, or provides you with a refill of your own pain medication.

 

DISCIPLINARY SANCTIONS

 

  • The Pain Program will impose disciplinary sanctions on individuals who violate the above standards.
  • Disciplinary sanctions include, but are not limited to: oral warning, written warning or reprimand, voluntary or mandatory counseling, probation, restriction, expulsion and referral for prosecution, immediate discontinuation of the medication therapy without substitution, expulsion without referral or follow-up.
  • The Pain Program reserves the right to apply any or all of these sanctions, as we deem necessary.
  • The Pain Program reserves the right to select and apply sanctions in any order that we deem adequate, including the application of multiple sanctions.
  • Violation of the above standards may result in immediate termination of the patient-physician relationship and therefore termination of treatment and expulsion from the Pain Program.
  • The patient is responsible, and encouraged to seek admission and treatment at specialized facilities, for the purpose of detoxification.
  • Some violations of this agreement will result in immediate notification to the Police and/or SBI (State Bureau of Investigations), and may result in the arrest and prosecution of the patient.
  • The Pain Program reserves the right to inform authorities, referring physicians, and the State Board of medical examiners, of violations to this agreement. This may result in the labeling of the patient as a ìDrug-Addictî or ìDrug-Seekingî patient, which in turn will make it illegal for any licensed physician to prescribe any controlled substances to this patient, ever again.