Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
STANDARD CONTROLLED SUBSTANCE
MEDICATION MANAGEMENT AGREEMENT 2013
With the current medical and legal atmosphere regarding
controlled substances, it has been recommended that all
pain practices have a similar medication agreement. Legal
and medical organizations have worked with the California
Medical Board, the DEA, and other societies to help create
a standard agreement that can be customized for use in
every office.
DISCUSSION BY DR. ANDERSON
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
Because of legal recommendations, I am amending your
current medication management agreement with this
newer standard opioid agreement. The information in this
agreement is an update to—not a replacement for—your
current agreement. In those cases where this agreement
differs from the prior agreement, this newer agreement
will supersede the prior agreement.
Please remember that this agreement is customized from a
standard medication management agreement that was
authored by lawyers and physicians. I did not write it.
In reading this agreement myself, I did notice that it is
much stricter than the prior agreement. I was initially
concerned about the tighter regulations and requirements
and how that would affect patients. For example, there are
no second chances for being marijuana positive on urine
testing, for using more medication than prescribed, or for
obtaining a prescription from another physician. The new
standard agreement requires participation in the newer
National health initiatives such as weight control, exercise
programs, and cessation of smoking.
However, after I thought about it, the new agreement really
should not have a negative impact on my patients. I
believe that my patients are chronic pain patients with
true physical chronic pain who require their
treatments to improve function. In fact, the stricter new
rules will help prove that my patients are compliant and
trustworthy. By continuing to follow the rules, they will
provide permanent evidence in the medical record that
they are, in fact, legitimate chronic pain patients.
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INTRODUCTION
The decision to use opioid (narcotic) medications was made because of my specific
condition or because other treatments have not helped my pain. Because Dr.
Anderson is prescribing such medication for me to help manage my pain, when I
sign this form I acknowledge that I understand and agree to the following conditions
to make my treatment as safe and successful as possible. Please place your initials
after each paragraph to indicate that you have read the paragraph.
1.
I am aware that the use of such medicine has certain risks associated with it,
including but not limited to: sleepiness or drowsiness, constipation, nausea,
itching, vomiting, dizziness, allergic reaction, slowing of breathing rate,
death, slowing of reflexes or reaction time, physical dependence, tolerance to
analgesia (a loss of pain reduction), addiction, and the possibility that the
medicines will not provide complete pain relief. INITIALS ________
2.
I understand that the main treatment goal is to improve my ability to function
by reducing pain. In consideration of that goal and the fact that I am being
given potent medication to help me reach that goal, I agree to help myself by
following better health habits: exercising, controlling my weight, and
avoiding the use of alcohol and tobacco. I understand that only by following a
healthier lifestyle can I hope to have the most successful outcome to my pain
management treatment. INITIALS ________
3.
In understand that the long-term advantages and disadvantages of chronic
opioid use have not been determined and that treatment may change while I
am under Dr. Anderson’s care. I understand, accept, and agree that unknown
risks may be associated with the long-term use of controlled substances and
that my physician will advise me as knowledge and training advances are
made, and will make appropriate treatment changes. I also know there may
be other non-opioid options for my pain control. INITIALS ________
4.
I agree to tell my doctor about all other medicine and treatments that I am
receiving. I will not request or accept controlled substance pain medications
from any other physician or individual while I am receiving such medications
from Dr. Anderson. To do so may endanger my health and our physicianpatient relationship. The only four exceptions are:
1) medication prescribed while I am admitted to a hospital, taken only
during the hospitalization;
2) medication prescribed by a surgeon immediately after surgery
provided both Dr. Anderson and the surgeon are aware of the situation
before the prescription occurs;
3) medications prescribed in cases where a patient may have two
different types of insurance coverage and because of the two insurance
plans, two different physicians must address chronic pain, provided
that both physicians are aware of the situation before the prescription
occurs;
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4) medication refills provided by the patient’s primary care practice in
those rare cases where the medications were due but Dr. Anderson was
unavailable, provided that both offices are aware of the situation before
the prescription occurs. INITIALS ________
5.
I agree to keep all scheduled appointments.
INITIALS ________
6.
At each visit, Dr. Anderson will evaluate me for pain relief, side effects,
function, and abnormal behavior that may indicate addiction. I understand
that evaluation may also include recommended lab work to monitor my
medication’s efficacy. I must keep Dr. Anderson fully informed of any
changes, Emergency Room visits, lost or stolen medications, or any other
circumstances affecting my health and well-being. INITIALS ________
7.
Dr. Anderson may refer me to another physician for a second opinion while I
am receiving controlled substances. I understand that if I do not obtain this
second opinion, Dr. Anderson may discontinue my medications or refill them
with a tapering dose to discontinue my use of them. INITIALS ________
8.
You have my permission to discuss my pain condition and my pain treatments
with my spouse or significant other. INITIALS ________
9.
I understand that driving a motor vehicle may be hazardous while taking
controlled substances and that it is my responsibility to comply with the laws
of this state and conduct myself safely while taking the medication prescribed.
We do not implicitly or explicitly provide permission to drive or to engage in
dangerous activities. INITIALS ________
10.
I will not be involved in activities that may be dangerous to me or to 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 operating a motor
vehicle, working at unprotected heights, or being responsible for another
individual who is unable to care for himself or herself. We do not implicitly or
explicitly provide permission to drive or to engage in dangerous activities.
INITIALS ________
11.
I will take my personal medications as directed. I will not tamper with
prescribed medications by cutting, crushing, or by any other means altering
the intended dose of medication. I will not take the medications by any other
than the directed route of administration (usually oral). INITIALS ________
12.
I will not adjust the medications by myself. I will discuss with Dr. Anderson
any change in dosage I feel I need at the next appointment. I will not increase
the dose or take an extra dose unless directly authorized to do so by Dr.
Anderson. INITIALS ________
13.
I will not hoard my medications. If I am doing better and I am able to control
my pain with fewer narcotics, I will inform Dr. Anderson. If I have lowered my
dose, I will inform Dr. Anderson. INITIALS ________
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14.
I am responsible for keeping track of the amount of medications left on my
prescription and I will plan ahead for arrangements to refill my prescriptions
in a timely manner so I will not run out of medications. If I run out of
medications, I may go through withdrawal. INITIALS ________
15.
I understand that I must make necessary arrangement to alert Dr. Anderson of
my need for a refill five (5) working days before they run out. If I fail to
provide five (5) working days’ notice, I may not be able to receive the
prescription in a timely manner and may undergo withdrawal. Medications
will not be refilled early, even if they have been lost or stolen. Medication
refill requests made on Fridays, weekends, or holidays will not be honored
absent special circumstances. INITIALS ________
16.
I have been fully informed by Dr. Anderson regarding the potential
psychological dependence on a controlled substance. I know that some
persons may develop a tolerance, which is the need to increase the dose of
the medication to achieve the desired effect. I know that I may become
physically dependent on the medication. This will occur if I am on the
medication for even just a few weeks; when I stop the medication I must do so
slowly and under medical supervision or I may have withdrawal symptoms.
INITIALS ________
17.
I understand that some rare situations may arise where one of my healthcare
practitioners may make the clinical decision that the use of controlled
substance (narcotic) pain medication may be too dangerous to continue, even
long enough to taper off. In such cases, I understand that I may experience
narcotic withdrawal. INITIALS ________
18.
I understand that if I fail to comply with the guidelines in this agreement and
the information on my prescription labels; if I obtain narcotics elsewhere
(even from a physician); if I use illicit drugs; if I share narcotics with others; or
if I alter a prescription, our doctor-patient relationship will be terminated.
INITIALS ________
PATIENT:
Name: ______________________ Date: _____________ Signature: _________________
PATIENT SPOUSE OR SIGNIFICANT OTHER:
Name: ______________________ Date: _____________ Signature: _________________
WITNESS, IF NO SPOUSE OR SIGNIFICANT OTHER:
Name: ______________________ Date: _____________ Signature: _________________