Page 1 Put smething about the conditions under which we will
Research and clinical experience suggests opioid (narcotic) pain medications are helpful for some patients
with chronic pain. The amount of pain relief any one patient will have is hard to predict, and a trial of opioid
medication is the only way to find out. Opioid medications can have side effects and there are special
problems to watch out for. Occasionally the side effects are severe enough that the medication is not worth
the side effects and has to be discontinued. The main side effects and risks are spelled out in this
agreement/informed consent. We also address some of the special circumstances related to these
medicines. Opioids are special compared to most other medicines because they have street value and
because they are medicines to which people can become addicted, although this is not as common as most
people think.
P ATIENT R ESPONSIBILITY : I, _________________________________, as a patient of __________________, have
received a copy of this agreement and consent and I agree that:
1. I understand that Opioids/narcotics are unlikely to eliminate all my pain. Reasonable expectations include improved comfort, increased activity tolerance, improved sleep.
MANAGING THE MEDICATION
2. I will receive opioid pain medications, sedative medication, and muscle relaxants from no other physician besides my IPCA doctor or his/her designee. If I do obtain medications from another physician from an
emergency room or after surgery, I will notify my IPCA doctor as soon as possible.
3. I will have all medications prescribed by this office filled at one pharmacy (or pharmacy chain), if possible. If, for whatever reasons (i.e., medication not stocked by pharmacy, financial or insurance
purposes), I have some or all prescriptions filled at a pharmacy other than the one submitted to this
clinic, it is my responsibility to advise the IPCA staff.
4. I will follow the IPCA procedure for getting refills: Call my doctor to leave a message requesting a refill one week in advance of running out of medications. I understand my doctor will not refill these
medications during evenings or weekends.
5. I will manage my medications responsibly: 5.1. It is my responsibility to not run short of my prescriptions. I will verify the number of pills dispensed prior to leaving the pharmacy when I pick up my prescription. 5.2. I will secure my medications in a safe, locked area at home where they cannot be lost, destroyed, stolen or ingested by other adults, children, or pets. (please read the warning on this subject at
the end of this document i ). 5.3. I will take my medication exactly as prescribed and not in excess of my doctor's instruction. If my pain is not managed, I agree to call my doctor prior to taking any extra medicine. 5.4. I understand that if my medications are lost or stolen, or if I run out early, it is my doctors policy to not re-write prescriptions, and that I will not receive a new prescription until the next regular refill
date. This may mean that I will experience physical withdrawal symptoms. 5.5. I will use whatever means necessary (notebook, tape recorder) to record and remember my doctors instructions and warnings related to opioids at clinic visits. 6. I agree to provide a written explanation for my medical record if I ask for early refills, if I loose prescriptions, if I have them stolen, or if I obtain medications from a source other than IPCA
7. I will not take illegal drugs or any additional opioid pain medications not prescribed by this office.
Opioid Pain Medication Agreement and Informed Consent INTEGRATIVE PAIN CENTER OF ARIZONA Initial: Initial: Page 2 UNDERSTANDING SIDE EFFECTS AND RISKS
8. I have read and understand the following about side effects of opioids: they include, but may not be limited to
Mental side effects: mental slowness, impaired judgement, feeling drunk, dizziness, drowsiness, poor
concentration, shakiness, poor coordination, increased tiredness
Other side effects: tolerance, the capacity to experience withdrawl symptoms if I stop the medicine
suddenly, interactions with other drugs, nausea, itching, rash, flushing, sweating, dry mouth, poor sex drive,
new or increased leg or foot swelling, difficulty urinating, constipation, increased joint pain, sweats, new
headache, skin irritation at the site of medication patches. Palpitations (a feeling of rapid heart beating)
and dizziness may occur, especially with methadone. Report these to your doctor because they may
mean that the medicine is affecting your heart badly, and further testing may be needed to find out if this
is the case.
Dry mouth is a common side effect that may lead to increased dental problems such as cavities. I have
reviewed the National Institutes of Health dry mouth patient education handout provided with this
agreement. I will consult with a dentist if I need to continue these medications and severe dry mouth
occurs.
I understand that side effects may require my doctor to stop or switch medications and that if my doctor
thinks that I am mentally impaired, I give my consent that he/she may contact whoever necessary
(family, friends, employer, other healthcare providers, etc.) to protect me or others.
9. I have read and understand the following about mental effects of opioids: 9.1. Alcohol, sleeping aids, sedatives and some antianxiety medications, antidepressants, antihistamines, antiseizure medicines, and muscle relaxants are some of the medicines that can
multiply and increase the mental side effects of opioids, and I must be extra vigilant for mental
impairment if I take these substances along with opioids. I will ask my doctor if I am unsure if it is
safe to combine opioids with any of the other medicines that I take. 9.2. I agree not to drive, carry or use a firearm, operate dangerous machinery, or serve, in any capacity related to personal and public safety, if I feel impaired, tired, or mentally foggy. 9.3. I understand that it is possible to be cited for DUI if a law enforcement officer finds on a field test that I am operating a motor vehicle while mentally impaired by my medication. 10. I understand that I will develop the capacity to experience physical withdrawal symptoms (headache, nausea, vomiting, chills, diarrhea, muscle aches, and malaise) if I take opioid medications for more that a
few months. This is NOT addiction. I understand that I can always stop opioids without withdrawal
symptoms if I taper the medicine slowly under a doctors care. I understand that serious dehydration and
chemical imbalance can occur if I go through withdrawal and cannot eat or drink for a prolonged period,
and that I should seek help in an emergency room or urgent care center for rehydration if this should
ever occur.
11. I understand that it is possible to develop addiction (psychological dependence) to opioids, but that this is fairly uncommon. My IPCA doctor will be monitoring for this and will take appropriate action should the
warning signs start to appear.
Concerning women: I will do everything I can to avoid getting pregnant while taking these medications,
which could bring harm to a fetus and require the newborn to go through detoxifcation. To the best of my
knowledge, I am presently not pregnant. Opioids are classified as category C in pregnancy (there is
unknown safety, animal studies have shown an adverse effect, and there are no human studies).

MONITORING USE OF THE MEDICATION
12. I give consent to allow my doctor or his/her designee to consult with any physician or pharmacist or family member or friends in this, or any other state, about my use, or possible abuse, of medications,
alcohol and/or illicit drugs. I understand that this means that IPCA staff may have to reveal details of
my medical history to family members and to others who do not have a legal obligation to protect this
information.
13. I will submit to a random urine specimen and/or alcohol breath test whenever my doctor requests, to test for illegal or illicit drugs, alcohol consumption, and/or compliance. I will bring all my medication with me to
the clinic if asked to do so. If I refuse urine screening or alcohol breath testing on the day it is
requested, if a urine specimen is tampered with, if illegal drugs or narcotics/sedatives that my IPCA
doctor is not prescribing are detected by urinalysis, or if I fall short on a pill count I understand that my Initial:
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Page 3 doctor may discharge me from care for being in violation of this contract, and will notify my primary care
physician, my referring physician, and my pharmacist of the reasons for the discharge.
14. I understand and give my consent that my doctor, at his or her discretion, may discontinue opioid therapy if I do not follow the above plan, if I do not treat the IPCA staff with reasonable respect, or if he/she
believes that my being on opioid pain medications is either harming me or not helping me.
CONTINUING THE PRESCRIPTIONS

15. I understand that there is an administrative fee of 20.00 for processing prescription refills by phone. I have reviewed the education information provided with this agreement
16. I understand that my IPCA doctor is initiating/continuing opioid therapy with the assumption that my primary care physician will eventually be asked to assume prescribing responsibility once I am on a
stable dose. I understand that if it my primary care doctor is unavailable for this aspect of my routine
medical care, my IPCA doctor may taper me off medications, because IPCA is not able to sustain routine
prescribing of medication for a large number of patients and also remain available for consultation
services.
17. If all parties are in agreement you may transfer this contract to my primary care physician so he/she can assume responsibility for prescribing my pain medications.


.
_________________________________
Patient D ATE : ____________________________

i This warning is found on methadone manufacturers labeling, but this warning applies to all opioid/narcotic medications : Keep opioids/narcotics in a secure place out of the reach of children and other household members. Accidental or
deliberate ingestion by a child may cause respiratory depression that can result in death. Patients and their caregivers
should be advised to discard unused medication in such a way that individuals other than the patient for whom it was
originally prescribed will not come in contact with the drug.

Furthermore, you may be held liable by civil courts, or even prosecuted in criminal court, if others use your medication
either with your consent or because the medication was left unsecured - even if it was in your home. Keep the
medication safe from others. Initial: