Philip Matthews DO
Healing through compassionate, holistic pain management
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LONG-TERM OPIOID USE AGREEMENT
LONG-TERM OPIOID USE AGREEMENT
FOR CHRONIC PAIN
The purpose of this agreement is to protect your access to controlled substances and to protect Dr Matthews’ ability to prescribe for you.
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 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 Dr Matthews to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.
The pharmacy that you have selected is:
• All controlled substances must come from Dr Matthews, or during his absence, from a covering physician, unless specific authorization is obtained for an exception. (Multiple sources can lead to untoward drug interactions or poor coordination of treatment.) An exception will be made when you are admitted to a hospital for appropriate care. Your attending physician in the hospital may consult with Dr Matthews to obtain appropriate medical records regarding your pain management.
• All controlled substances must be obtained at the same pharmacy, where possible. Should the need arise to change pharmacies, our office must be informed.
• 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.
• Dr Matthews 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. Otherwise, confidentiality of your medical records will be maintained in accordance with HIPAA rules and regulations.
• You agree to take medications at the dose and frequency prescribed. You must obtain authorization from Dr Matthews to change your dose.
• You agree to not abuse alcohol or use other medically unauthorized or illicit substances. As marijuana is illegal even for medical purposes by the federal government, you shall abstain from its use.
• Unannounced urine or serum toxicology screens may be requested, and your cooperation is required. Presence of unauthorized substances may prompt referral for assessment for addictive disorder and may result in the discontinuance of the controlled medications.
• Prescriptions and bottles of opioid 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 medications and prescriptions. They should not be left where others might see or otherwise have access to them (such as leaving them in a medicine cabinet). It is highly recommended that you obtain a safe in which to keep your opioid medications except for whatever you keep on your person.
• Original containers of medications should be brought in to each office visit upon request by Dr Matthews.
• 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 such as when you are in the act of taking the medications or while placing the medication into time-marked containers for future use.
• Medications may not be replaced if they are lost, get wet, are destroyed, left on an airplane, etc. If your medication has been stolen and you submit a police report regarding the theft, an exception may be made. Exceptions to this rule are at the discretion of Dr Matthews.
• Early refills will generally not be given.
• Prescriptions may be issued early if Dr Matthews or you will be out of town when a refill is due. These prescriptions will contain instructions to the pharmacist that they will not be filled prior to the appropriate date.
• If responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to your record of controlled substances administration.
• It is understood that failure to adhere to these policies may result in tapering or cessation of therapy with the controlled substances prescribed by Dr Matthews or may require a referral for further specialty assessment.
• Other practitioners or pharmacists may report violations of the agreement back to Dr Matthews. Copies of this agreement may be released to emergency departments, urgent care facilities, and pharmacies whenever appropriate.
• Dr Matthews may notify proper authorities if he has reason to believe that you have engaged in illegal activity.
• If you violate the terms of this agreement, Dr Matthews will document the violation and his response, as well as the rationale of treatment in your medical record.
• Refills of medications are contingent on keeping scheduled appointments. All patients using opioids for chronic pain must be seen at least every three months or more often except under special circumstances.
• Please do not phone for routine prescription refills after hours or on weekends. If you run out of medications because you did not arrange in time for a refill, Dr Matthews may call in medications to modulate withdrawal should it occur. Routine refills will be handled at regular hours on the next business day.
• It should be understood that any medical treatment is initially a trial, and that continued prescription is contingent on evidence of functional benefit.
• The risks and potential benefits of these therapies are explained in the informed consent and frequently asked questions section of the website “philipmatthewsdo.com”. You acknowledge that you have received such explanations and have discussed any and all matters about which you still need information or clarity.
• You affirm that you have full rights and power to sign and be bound by this agreement, and that you have read, understand, and accept all of its terms.
Philip Matthews, DO
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Dr Matthews in Mercer Slough
Woodridge Bldg from Mercer Slough
Address, Phone, Fax
Philip Matthews DO