New Patient Medical History (Page 7 of 10) in pdf

Weill Cornell Pain Medicine

PAIN MEDICINE PRACTICE CONTROLLED DRUG PRESCRIPTION AGREEMENT

The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you.

These medications are regulated by the United States Food and Drug Administration, New York State, and Drug

Enforcement Administration.

The long-term use of such substances as opioids (narcotic analgesics), benzodiazepine tranquilizers, and barbiturate sedatives is

controversial because of uncertainty regarding the extent to which they provide long-term benefit. There is also the risk of an

addictive disorder developing or of relapse occurring in a person with a prior addiction. The extent of this risk is not certain.

Because these drugs have potential for abuse, misuse, or diversion, strict accountability is necessary when use is prolonged.

For this reason the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of

the physician whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat

your chronic pain.

1. If you are prescribed opioids from the pain clinic, future prescriptions must come from the physician whose signature appears

below or, during his or her absence, by the covering physician, unless specific authorization is obtained for an exception.

However, if you reach a “Stable” dose of medication that allows a satisfactory balance of functional and pain improvement and

minimizes side effects, you may be transferred back to your primary care provider for future prescriptions. Your Pain Physician

will coordinate this. Multiple sources can lead to untoward drug interactions or poor coordination of treatment.

2. All controlled substances must be obtained at the same pharmacy, where possible. Should the need arise to change pharmacies,

our office must be informed.

3. You are expected to inform our office of any new medications or medical conditions, and of any adverse

effects you experience from any of the medications that you take.

4. The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing

pharmacists or other professionals who provide your health care for purposes of maintaining accountability.

5. You may not share, sell, or permit others to have access to these medications.

6. These drugs should be taken as prescribed including dose and frequency and may not be altered without direct approval from

your Physician. Also they should not be stopped abruptly, as a withdrawal syndrome may develop.

7. Unannounced urine, saliva, or serum toxicology screens may be requested, and your cooperation is required. Presence of

unauthorized substances will be noted in your medical record and may prompt referral for assessment for addictive disorder

along with discontinuation of your opioid prescriptions.

8. These medications may be sought by other individuals with chemical dependency and should be closely safeguarded. It is

expected that you will take the highest possible degree of care with your medication and prescription. They should not be left

where others might see or otherwise have access to them. Since the drugs may be hazardous or lethal to a person who is not

tolerant to their effects, especially a child, you must keep them out of reach of such people.

9. You may be asked to bring original containers of prescribed medications to your follow up visit.

10. You will refrain from use of illegal drugs or alcohol with the use of these medications.

11. You understand that you may place yourself or others at risk if you drive or operate heavy machinery.

12. You may be asked to participate in psychological or psychiatric assessments as part of your treatment in order to best monitor

use of these medications.

New Patient Medical History Page 7