Opiate Use Agreement
Patient's Name: ________________________________
(If your reading ability is less than 8th grade please ask the medical assistant to go over the agreement with you.)
This contract is an agreement between
you and Dr. Rotchford. Its purpose is to help provide you with the best of care
while you are receiving narcotics for pain management. No changes to the agreement
are to be made without your permission and that of Dr. Rotchford. (Please don't
expect the receptionist, medical assistant, or even another physician to change
the agreement once signed) Of course, if you choose to stop care with Dr. Rotchford
the agreement becomes void. So please do not change any aspect of the agreement
without first obtaining permission directly from Dr. Rotchford. Any discussion
of or changes to of this agreement are expected to be made at the time of an
appointment. Revisions to this agreement require a new one to be signed with
the changes noted. If Dr. Rotchford makes changes to the agreement please help
remind him to have the medical assistant have a new one made and signed. Verbal
approval by any member of the physician's staff will not be honored. Any time
you do not follow your agreement we reserve the right to stop treating and prescribing
for you. If that occurs we will notify you in writing and give you up to four
weeks in order to find alternative care. Of course we will share our records
with your new physician after appropriate releases are signed. We want you to
receive the best of medical care for your pain problems. For this to happen
we understand that we need your help and honesty.
How is one to be honest about not being able to adhere to this agreement if
the relationship with Dr. Rotchford is threatened by being honest? The question
is especially pertinent if one is dependant on Dr. Rotchford for his/her medical
care? What's more, if you've had previous problems with addiction or adhering
to Dr's prescriptions it is likely that you will occasionally have problems
keeping this agreement. The answer is actually simple. It has never happened
that treatment with opiates is terminated by Dr. Rotchford soley because of
an occasional failure to adhere to this agreement. Rather, what you can expect
is for Dr. Rotchford to intervene in a way that will make it more likely for
you to be able to adhere to this agreement. Dr. Rotchford is ethically obliged
to report illegal behavior such as diversion of medications to other individuals.
Until now the only time Dr. Rotchford has terminated opiate prescriptions is
when a patient after breaking the agreement is unwilling to follow through with
recommendations to work at making this agreement work. Obviously, if one can't
adhere to this agreement something else needs to be done. Also, there is scientific
evidence that indicates that one is less likely to help a patient with a chronic
pain disorder, especially a patient with a chemical dependency problem, if continuity
of care is not encouraged. So there are many incentives for Dr. Rotchford to
work with you to assure continuity of care. We hope this explanation is reassuring
but please speak with Dr. Rotchford if you wish further clarification. Hopefully,
even if you are just tempted or have an urge to not adhere to this agreement
you will feel comfortable talking about it with Dr. Rotchford. Although he is
not always immediately available he most often will get back in touch with you
within 24 hours.
We have agreed that the following are suitable medication(s) for your condition.
These medications will not be changed without a new agreement signed by you
and Dr. Rotchford. For your safety we require that you pick one pharmacy and
obtain all of your medications through it. Name of Pharmacy: ____________________
____________________________________________________________________________________________________________________________________________________________________________________
Since many of the medications we
prescribe require new written prescriptions, our policy is to make refills only
at the time of your regular appointment. A regular appointment will be required
at least once every four weeks. Your request for refills will not be honored
before that day. At first we will not be able to honor your requests for extra
medications for trips out of town, etc. Later, based upon your history of compliance
and your medical stability we are able to make exceptions. If at all possible
these discussions need to be made at the time of a regular appointment.
Your written prescription and your drugs are like money. If you lose either
we will not replace them until your next scheduled visit. But please call Dr.
Rotchford immediately so that we can help you manage any withdrawal symptoms.
Please take extreme caution in protecting your medicines from loss or theft.
In the beginning and after each change in your contract we may request that
you keep detailed records of each time you take your medicine.
You agree by signing this agreement
that Dr. Rotchford is the only practitioner prescribing controlled substances
for you. Any prescribing clinician that you see as a patient you agree to inform
of this agreement and that you are taking an opioid for pain management. If,
in an emergency, you receive any medications from any other clinician for any
reason you must inform us as soon as possible. This includes hormones, birth
control pills, allergy medications, etc. You agree to inform Dr. Rotchford about
all other medicines and treatments that you are receiving. Illicit drugs are
not allowed. The possible exception is Marihuana. If you are using a cannabinoid
products (Marihuana) for pain management this needs to be negotiated with Dr.
Rotchford on a case by case basis. Hence, you agree to ABSTAIN from using any
inappropriate pain medication (Including alcohol) or other drugs and to continue
an effective pain management program while working with Dr. Rotchford.
The staff has been instructed to be courteous and show you respect. Please treat
them likewise. They are not permitted to change any aspect of this agreement
without a new one being signed by you and Dr. Rotchford.
It is important to us that you understand the proper use of your medications.
In order to help you better we might ask you to discuss what we told you at
your last visit. Some people find taking notes helpful. Education is an important
component of pain management. The best teachers, however, are unable to help
students who don't listen attentively.
We reserve the right to ask you to give us a urine specimen while you are at
our office or obtain one that day. It is necessary that the specimen is collected
by an assistant properly trained. The sample will be tested for controlled or
addictive substances. You may refuse to do this. Unwillingness to submit to
a breadth, blood, or urine test will be interpreted as a clear indicator that
you have been using mood-altering chemicals or drinking alcohol and that an
immediate change in your treatment regimen is indicated.
You are not permitted to share any of the medications that we prescribe with
anyone else. As stated above this represents illegal behavior and must be reported
to authorities.
We may require that you participate in active exercises or other forms of therapy.
We may ask that you demonstrate these to us to be sure you have been instructed
properly in their use. We may ask that you keep records of when and how many
exercises you do. We also require full access to medical records or discussion
with other practitioners/counselors that you are currently seeing or have seen
in the past. Effective pain management most often requires collaboration and
a team effort!
The less secrets one has when using a substance that can result in addictive
behavior the safer one is.
Likewise, we will be corresponding with your other health care providers but
given the sensitivity of some issues we will make professional decisions about
what information should be released. We will only release information to professionals
who you have indicated are part of your health care team ie: other physicians,
dentists, pharmacists, local emergency rooms, counselors, ministers). We also
have a letter directed to other prescribing health care providers. We recommend
that you read it, keep a copy of it on hand, and provide a copy to all prescribing
practitioners you see. We plan to send them a copy as well.
By signing below you are agreeing that you have read the information in this
agreement and that you understand it. In addition your signature indicates that
your questions have been answered to your satisfaction. You promise to fulfill
your part as a member of a team that is trying to help you with your pain. If
you do not feel that you can honor the commitments made in this contract, you
may notify us now and or at any time. If there are portions of this agreement
you are unwilling to adhere to Dr. Rotchford will continue to see you for pain
management but opiates will not be prescribed.
Before signing this agreement please also review our opiate information and consent form.
Signed_____________________________________________Date_______________
Witness__________________________________________________
________________________________
James K. Rotchford, MD
c:\forms\Opiate Use Agreement.wpd
May 28, 2004