Patient Consent for Chronic Opioid Therapy

Dr. ____________ is prescribing opioid medicine, sometimes called narcotic analgesics, to me for a diagnosis of ________________________________.

I understand that this decision was made because my condition is serious or that other treatments have not helped my pain.

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, slowing of reflexes or reaction time, physical dependence, tolerance to analgesia, addiction, over dosage and possibly that the medicine will not provide complete pain relief.

I am aware of the possible risks and benefits of other types of treatments that

do not involve the use of opioids. The other treatments include, but are not limited to, other classes of medications, minimally invasive treatments, physical therapy, chiropractic treatment, or surgery if indicated.

While I am taking opioid medications I agree not be involved in any activity that may be dangerous to me or 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. I understand that such activities include, but are not limited to: operating a motor vehicle, operating other equipment, working in unprotected heights or being responsible for an individual who is unable to care for himself or herself.

I am aware that certain other medicines such as nalbuphine (Nubain), pentazocine (Talwin) buprenorphine (Buprenex) and butorphanol (Stadol), may reverse the action of the medicine I am using for pain control. I understand that taking any of these medications while I am taking my pain medications can cause symptoms like those of a severe flu, called a withdrawal syndrome. I agree not to take any of these medicines and to tell all doctors treating me that I am taking an opioid as my pain medicine and that I cannot take any of the medicines listed above.

I am aware that addiction is defined as the use of a medicine even if it causes harm, having craving for a drug, feeling the need to use a drug and a decreased quality of life. I am aware that the chance of becoming addicted to my pain medicine is very low. I am aware that the development of addiction has been reported rarely in medical journals and is much more common in a person who has a family or personal history of addiction. I agree to tell my doctor all information about my past use of recreational or illegal drugs and any excessive use of alcohol. I also agree to inform my doctor of any treatment I have had for alcohol or drug use and any incidents in my past in which medical providers have expressed concern over my use of alcohol, recreational drugs, or prescribed medication. I also agree to inform my doctor of any drug use or excessive alcohol use in my family.

I understand that physical dependence is a normal, expected result of using these medicines for a long time. I understand that physical dependence is not the same as addiction. I am aware physical dependence means that if my pain medicine use is markedly decreased, stopped or reversed by some of the medicines noted above, I will experience a medical condition known as 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, irritability, aches throughout my body and a flu-like feeling. I am aware that opioid withdrawal is uncomfortable but not life-threatening.

I am aware that tolerance to analgesia means that after using opioid medications over time I may require more medicine to get the same amount of pain relief. I am aware that tolerance to analgesia does not seem to be a big problem for most patients with chronic pain however; it has been seen and may occur to me. If it occurs, increasing my dose of opioids may not help reduce pain but may cause unacceptable side effects. If I develop tolerance to opioids or if opioids do not seem to be helping my pain effectively I understand that my doctor may choose another form of treatment.

(Males only) I am aware that chronic opioid use has been associated with low testosterone levels in males. This may affect my mood, stamina, sexual desire and physical performance. I understand that my doctor may check my blood to see if my testosterone level is normal.

(Females only) If I plan to become pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetric doctor and this office to inform them. I am aware that should I carry a baby to delivery while taking these medications; the baby will be physically dependent upon opioids. I am aware that the use of opioids is not generally associated with a risk of birth defects. However, II acknowledge that birth defects can occur whether or not the mother is on medicines and that there is always a possibility that my child will have a birth defect while I am taking an opioid medication.

I have read this form or have had it read to me. I understand all of it. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. By signing this form voluntarily, I give my consent for the treatment of my pain with opioid medicines.

Patient Signature __________________________________________

Date: ____________________________________________________

Witness: __________________________________________________