PAIN MANAGEMENT AGREEMENT (TEMPLATE) LETTER OF UNDERSTANDING AND INFORMED CONSENT FOR THE USE OF CONTROLLED SUBSTANCES IN THE TREATMENT OF CHRONIC PAIN This letter of understanding is acknowledged by me and my pain clinician(s) in order to define my role in the management of chronic pain with the use of controlled substances (e.g., narcotic pain killers, opioids, etc.). It also outlines the risks and benefits of this form of treatment. 1. If I receive an acute medical procedure that requires pain medication (e.g., dental surgery), I will maintain my current pain control regimen and ask the other physician (e.g., dentist) to prescribe additional medication for acute pain relief. 2. I agree that this trial of treatment has been explained to me in such a way that I understand the purpose, possible side effects, risks, and benefits. I understand that there are potential complications and problems associated with this type of treatment. I have been informed that it is unrealistic to expect complete pain relief, though it is realistic to achieve a reduction in pain and related improvement in the quality of my life. 3. I understand that I may achieve significant pain relief for long periods of time using narcotic medication. Further, I am aware that complications could arise while using this medication (e.g., constipation, nausea, sedation, mental confusion). These side effects could potentially: a) mask physical pain secondary to other serious medical conditions, b) produce psychotic states, nightmares, hallucinations, or depressed mood, c) cause the development of short-term respiratory depression, nighttime muscle jerking, sweating, urinary retention, dry mouth, increased sweating, itching, and d) interact with other mind-altering medication such as sedatives, tranquilizers, sleeping pills, and alcohol which could result in a state of oversedation. 4. I understand that many side effects are temporary and may go away with time and ongoing treatment. Initially, the use of narcotic medication may cause drowsiness and a slowing of my reflexes. I further understand that I should avoid driving or using dangerous equipment that requires a high level of alertness. Persistence of drowsiness may be due to an interaction between narcotic and other sedating medication. 5. I understand that the use of narcotic medication will result in physical dependence on this medication and that a sudden decrease or discontinuation could lead to the symptoms of withdrawal. I understand that withdrawal is uncomfortable but not life-threatening. If I choose to stop this medication, I will first inform my pain clinician who may supervise a slow taper in order to avoid withdrawal symptoms. I agree to schedule routine follow-up appointments or phone contacts so that s/he may closely monitor my response to treatment. I may gradually experience tolerance to this medication, such that more is needed to achieve a desired effect. I understand that substitution of other medication, or an increase in my current dosage, may alleviate these problems for long periods of time. Page 1 of 2 6. If I am taking narcotic medication while pregnant, my child may be physically dependent at birth. I agree to immediately notify my obstetrician that I plan to take this medication. 7. Controlled substances prescribed on a long-term basis may present a very small risk of addiction. However, addiction is rare in patients who are prescribed narcotics for the purpose of managing chronic pain. I am aware that addiction to a narcotic medication is not the same thing as physical dependence. Rather, it involves the use or abuse of my prescription for non-medical purposes. Abuse involves the following: a) use to get high, b) rapidly increase in dosage when it is not indicated, or c) the sale/offer/share of my medication to or with others. I am aware that persons with a history of substance abuse or dependence may be at an increased risk of developing an addiction to narcotic medication. I will not use other sedating medication while I am prescribed narcotic medication unless my pain clinician is in approval. I also agree to refrain from the use of any mind-altering drugs including alcohol, marijuana, etc. (with the exception of nicotine and caffeine) unless the substance is prescribed and my pain clinician is agreeable. I agree to submit to random urine or blood screening at the request of my pain clinician and within any specified time frame in order to demonstrate that I am in compliance with the treatment as outlined. 8. While under the care of this clinic, I promise to use only it for my pain management unless, of course, I experience an acute medical emergency. I agree to notify my pain clinician of any acute medical or emergency services that I receive as soon as I am able to do so, particularly if I am prescribed additional medication. 9. It is my responsibility to contact my pain clinician prior to running out of medication so that I can receive refill(s) on schedule. I am aware that the pain clinic will not provide early refills and that it is my responsibility to maintain close attention to the expiration date. I agree to keep my medication in a safe and secure place so that it will not be misplaced, stolen, or otherwise lost. ___________________________________ ________________________________ Patient Signature Date Date Pain Clinician Signature Page 1 of 2