A Contract for Taking Opioids for Pain

A Contract for Taking Opioids for Pain

Many people who come to Novus Medical Detox Center arrive for various forms of being on opioids for pain. These patients did not purchase these drugs from a drug dealer so that they could get "high." They were not taking the drugs because they liked the "mellow" way it made them feel. They were taking the drugs to not be sick from withdrawal. They were taking the drugs as prescribed by a medical doctor and they were purchased at a pharmacy. Most of these patients who come to Novus are very upset.


They are upset because:
  • Their doctors never explained all the possible consequences of long-term opioid use for treatment of pain.
  • Their doctors never explained that the medical literature is full of information describing how the opioids actually increased a person's pain because they make the pain receptors more sensitive.
  • Many people rapidly became tolerant and were required to take more and more of the painkiller, and this interfered with their ability to function in life.
  • Their doctor did not explain the likely side effects and the very painful withdrawal symptoms if they stopped taking the opioids.
In the March, 2008 issue of Pain Physician, there is an article written by some prominent doctors who stated,
  • "It is concluded that, for long-term opioid therapy of 6 months or longer in managing chronic non-cancer pain, with improvement in function and reduction in pain, there is weak evidence for morphine and transdermal fentanyl.
  • However, there is limited or lack of evidence for all other controlled substances, including the most commonly used drugs, oxycodone and hydrocodone."
In other words, painkillers create many side effects and there is little evidence that they are effective if used for longer than six months. In that same issue of Pain Physician, an opioid contract between the patient and physician was set forth. While it was a good start, we don't think it provides the patient what the law requires-enough data to give the informed consent required by law. We propose that the following form be given to anyone who is considering using opioids (narcotic painkillers) for the control of pain. They should read it and they should ask their doctor to sign it and answer any questions that they have before taking opioids. OPIOID CONTRACT We are committed to doing all we can to treat your chronic pain condition. In some cases, controlled substances are used as a therapeutic option in the management of chronic pain and related anxiety and depression. The use of these controlled substances is regulated by state and federal agencies. This agreement is a tool to protect both you and the physician by establishing guidelines, within the laws, for proper controlled substance use. The words "we" and "our" refer to the facility or the doctor and the words "I", "you", "your", "me", or "my" refer to you, the patient. The word "opioids" refers to the class of narcotic painkillers like hydrocodone or oxycodone with brand names like Percocet, Lortab, OxyContin and Vicodin, and to methadone and morphine.
  1. I understand that chronic opioid therapy has been associated with not only addiction and abuse, but also multiple medical problems including the suppression of endocrine function resulting in low hormonal levels in men and women which may affect mood, stamina, sexual desire, and physical and sexual performance.
  2. I understand that constipation, vomiting, headaches, nausea, somnolence (feeling sleepy), pruritus (intense itchiness), asthenia (a loss of strength), and excessive sweating are additional common side effects.
  3. I acknowledge receipt of a copy of the side effects and dangerous drug interactions contained on the FDA-required label for the opioid that I am prescribed, and I agree that I will read it and if I have questions, I will get them answered before I start taking the opioids.
  4. I understand that if I take other medications to treat the above side effects, that these additional medications may create even more uncomfortable side effects.
  5. I understand that the active ingredient in most opioids is molecularly interchangeable with heroin and is actually "legal heroin."
  6. I understand that opioids can cause respiratory depression and this can lead to respiratory failure and death.
  7. I understand that opioids are particularly dangerous and life-threatening if taken by children and others who have not previously taken opioids, and I agree that I will ensure that I always keep a count of my drugs and keep them out of the reach of others, adults and children alike, because opioids can be as lethal as a loaded gun.
  8. I understand that if someone obtains opioids prescribed to me and the improper use of these opioids causes the death or injury of another, that I may have criminal and civil liability.
  9. I understand that in most cases long-term opioid therapy is only blocking the pain signals but is not treating the actual cause of the pain.
  10. I understand that because the opioid blocks pain signals to my brain, it will likely also block pain signals from other sources of pain, and this may prevent me from realizing that I am harming other parts of my body-like muscle tears, muscle sprains and even tooth decay. Not being able to sense harm to other parts of my body may result in damage to other areas of my body.
  11. I have been informed that long-term and/or high doses of pain medication often cause increased levels of pain known as opioid-induced hyperalgesia (pain medicine causing more pain) where simple touch will be predicted as pain, and that pain can gradually increase in intensity and also by location, causing the body to hurt all over. I understand that opioid-induced hyperalgesia is a normal, expected result of using these medications for a long period of time.
  12. I have been informed and understand that there are alternative treatments for my condition which do not involve drugs or surgery, but I have decided that I would rather take the opioids.
  13. I am aware that continued use of opioids will lead to physical dependence. Physical dependence means that if my opioid use is markedly decreased, stopped, or reversed, I will experience a withdrawal syndrome. This means I may have any or all of the following symptoms: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, vomiting, irritability, aches throughout my body and a flu-like feeling. I am aware that opioid withdrawal can be very uncomfortable, but is not normally life-threatening.
  14. For female patients, if I plan to become pregnant or believe that I have become pregnant while taking this medication, I am aware that, should I carry the baby to delivery while taking these medications, the baby will be physically dependent upon opioids. I will immediately call my obstetrician and this office to inform them of my pregnancy. I am also aware that opioids may cause a birth defect, even though it is extremely rare.
  15. I am aware that many opioid users develop a tolerance to opioids. This means that I will have to be increasing the dosages of the opioids to get the same amount of pain relief because my receptors will not be as sensitive to the opioid as when I started taking the drug. If tolerance 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 stop their use and this will lead to the withdrawal symptoms stated above.
  16. I understand that the opioids that my physician is prescribing are controlled substances and that it is a felony for me to share, sell, or otherwise permit others, including your spouse or family members, to have access to any controlled substances that you have been prescribed. I understand that anyone found in possession of my prescribed opioids is guilty of a crime and can be fined or imprisoned.
  17. All controlled substances must come from the physician whose signature appears below or during his/her absence, by the covering physician, unless specific authorization is obtained for an exception.
  18. I understand that I must tell the physician whose signature appears below or during his/her absence, the physician who is cov­ering for him or her, all drugs that I am taking, have purchased, or have obtained, even over-the-counter medications. Failure to do so may result in drug interactions or overdoses that could result in harm to me, including death.
  19. I will not seek prescriptions for controlled substances from any other physician, health care provider, or dentist. I understand it is unlawful to be prescribed the same controlled medication by more than one physi­cian at a time without each physician's knowledge.
  20. I also understand that it is unlawful to obtain or to attempt to obtain a prescription for a controlled substance by knowingly misrepresenting facts to a physician or his/her staff or knowingly withholding facts from a physician or his/her staff (including failure to inform the physician or his/her staff of all controlled substances that I have been prescribed).
  21. All controlled substances must be obtained at the same pharmacy where possible. Should the need arise to change pharmacies, our office must be informed. The pharmacy that you have selected is: ________________________; Phone:_____________
  22. Early refills will not be given. Renewals are based upon keeping scheduled appointments. Please do not make excessive phone calls for prescriptions or early refills and do not phone for refills after hours or on weekends.
  23. Unannounced pill counts, random urine or serum or planned drug screening may be requested from you and your cooperation is required. Presence of unauthorized substances in urine or serum toxicology screens may result in your discharge from the facility and its physicians and staff.
  24. I understand that consuming alcohol in conjunction with opioid use can result in serious problems. I understand that other legal and illegal drugs can create problems in how the opioids are metabolized and this can create potentially serious adverse drug reactions.
  25. I will not use, purchase, or otherwise obtain any other legal or illegal drugs except as specifically authorized by the physician whose signa­ture appears below or during his/her absence, by the covering physician, as set forth in Section 2 above. I will not use, purchase, or otherwise obtain any illegal drugs, including marijuana, cocaine, etc.
  26. I understand that driving while under the influence of any substance, including a prescribed controlled substance or any combination of substances (e.g., alcohol and prescription drugs), which impairs my driving ability, may result in DUI charges, and I agree not to drive until my physician is comfortable that the opioids will not adversely affect my ability to drive.
  27. Medications or written prescriptions may not be replaced if they are lost, stolen, get wet, are destroyed, left on an airplane, etc. If my medication has been stolen, it will not be replaced unless explicit proof is provided with direct evidence from the authorities. A report narrating what I told the authorities is not enough.
  28. In the event I am arrested or incarcerated related to legal or illegal drugs (including alcohol), refills on controlled substances will not be given.
  29. I understand that failure to adhere to these policies may result in cessation of therapy with controlled substances prescribed by this physician and other physicians at the facility and that law enforcement officials may be contacted.
  30. I also understand that the prescribing physician has permission to discuss all diagnostic and treatment details, including medications, with dispensing pharmacists, other professionals who provide my health care, or ap­propriate drug and law enforcement agencies for the purpose of maintaining accountability.
  31. I affirm that I have full right and power to sign and to be bound by this agreement, that I have read it, and understand and accept all of its terms. A copy of this document has been given to me.
  32. _____________________________________________ PATIENT'S FULL NAME ______________________________ Date:____________________ PATIENT'S SIGNATURE ______________________________ Date:____________________ PHYSICIAN'S SIGNATURE
CONCLUSION Nearly 2,500 years ago, Hippocrates, the Greek physician and the man who is considered the father of medicine, admonished his students that when they considered treatment for a patient they should,
  • "First do no harm."
  • Refusing to treat the cause of pain but only using opioid painkillers to block the pain signals for non-terminal patients does harm.
  • The opioids don't treat the cause of the pain but merely act as an anesthetic so that a person doesn't feel the pain as much.
  • Opioids not only don't work for many people taking these drugs longer than six months, but they also create many other problems.
  • However, the biggest fault is that the physician is not curing the problem causing the pain, but making the patient a slave to Big Pharma.
  • Once hooked, the patient can't stop without experiencing severe discomfort from the withdrawal and often still has the pain that was there in the beginning.
  • Maybe in a few cases the use of opioids is the only alternative to unbearable pain-like for cancer patients or end-of-life patients.
  • However, it cannot be argued that, where possible, the best situation is to actually handle the source of the pain and then the person is free of these dangerous drugs.
If people understand the provisions of the Opioid Contract, most will elect to at least seek treatment for the cause of their pain. If there is absolutely no other option, only then should they consider the long-term use of opioids.

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