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PEDIATRIC PATIENT PROVIDER PATIENT PROVIDER AGREEMENT AGREEMENT ON OPIOID THERAPY PATIENTON OPIOID PROVIDER THERAPY AGREEM

        Purpose: The purpose of this agreement is to protect your access to controlled substances and to         protect our ability to prescribe for you/ your child. This agreement is reviewed    continuously and signed by patients/guardians in our practice. 1( !"     $! $       $  ! 1. Your provider has determined that you/your child may be a candidate for opioid therapy because of         )"! ( their potential benefits to decrease pain and/or improve function. 2(  " #  $  ! ! (    $ 2. There are several risks and side effects which may limit or end the continued use of . Risks of  !  !  ' opioid therapy include but are not limited to: Respiratory Depression Sweating Low Testosterone Hives Itching Potential for Addiction Worse Pain Over Time Sudden Death Risk of Death with Obstructive Decreased Immune Irregular/Absent Inability to Control Pain with Increasing Constipation Potential for Abuse Sedation/Sleepy Risk of Death with Obstructive Sleep Apnea Sleep Apnea Function Menstruation Doses of Opioids (Tolerance) +$*$ /$ )/-*1$ -"- ( )/. Nausea/Vomiting Low Testosterone Seizures Inability to Control Pain with Increasing Doses of Opioids Nausea / Vomiting Constipation Tremors Altered Mental Status Sweating Confusion Ability to Complete Suicide Risk of Others Using/Stealing Your Drugs Potential Harm to Unborn or Worse Pain Over Time Decreased Bone Risk of Others Using/Stealing Your Drugs  $.0..$*)*0/-$.&.)  ) 7/.> Newborn Baby (if breastfeeding) (Hyperalgesia) Density Hives Tremors Withdrawals Arrhythmia (unique opioids) Itching Weight Gain Withdrawals Arrhythmia (unique opioids) Weight Gain Irregular/Absent Impairment While Driving *Mixing with or Other Drugs increases many of the Menstruation other risks listed Impairment while Driving or Depressed Mood Potential for Addiction *Mixing with Alcohol or Other Drugs Operating Machinery increases many of the other risks listed Depressed Mood Decreased Immune Respiratory Depression Potential Harm to Unborn or Newborn Baby (if breastfeeding) *0./$''#1 UW($)0/ ..*/# ( .." #./**( !-*(? Function Seizures Potential for Abuse Sudden Death Drowsiness 3. Patient/guardian will allow the provider to communicate about treatment with all other medical and 3( !# #$!"  !  ! #        mental health providers. $.&.. ..( )/**'. " ( 4. Patient will only receive opioid prescriptions from this clinic, and guardian will inform the provider of 4( !#$ "      &  #$!"  $ any changes of any kind. - ) -) +$*$ .. ..( )/!*-/$ )/.2$/#$)@ 1$. L@M      $ ( 5. Patient’s guardian is responsible for safeguarding . Lost, misplaced, or stolen J 5( !   !    (&  &    prescriptions or medications may not be replaced and may result in discontinuation of opioid therapy.  $      $!  !   $( 6. Any evidence of drug hoarding, taking any other pain medications from other physicians (including the emergency room), changing the dose, or not following this agreement may result in discontinuation of 6( !#             !#" ( $! J0-- )/+$*$ $.0.  .0- LM opioid therapy.  $       ( reement. 3) Scan this document with signatures and label into Scanned Clinical Documents. 7. Patients will take opioids as prescribed, under the guardian’s direct supervision. Early request for J$).4#*'*"$./. 7(  "   , $& & "&--#    "  refills may not be permitted. ( !"  $! 8. Patient may not share opioid medication with friends, family, or others    !     #' 9. Patient/guardian is expected to return to clinic as instructed by the provider for frequent follow up.               10. Provider may do routine drug screening to ensure safe use of the medication. Higher dose and high risk - .-$+/$*)-0"*)$/*-$)"-*"-(. 8(  $ ! ! ! !   !       (   *    * behavior (drinking alcohol, using other drugs, early refill requests, failing to submit or tampering with  ",   &! !& $!& !  # urine) should result in more frequent testing. !- $!!( 11. Provider may invite patient with high-risk behavior to come for more frequent clinic visits and/or to -$) -0"- )$)". 10( $"$! !  "  ) !( !  count pills. Failure to bring in appropriate number of pills would demonstrate that the risk of continuing  !  $    !    $( chronic opioid therapy is high. 10(# ! $" !  )   $( 12. Patient will agree to psychological assessment as part of opioid therapy. 11(               13. Provider may taper off opioids if they are no longer controlling pain or improving function, if side # - /* /0-))0. -0".>*'$ //$*).;#-($ .> effects are severe, if appointments are frequently missed, if behavior is high-risk, or if this agreement is  !"  $ "   !!! #  $# ! ( not followed. The provider may decide that if risks outweigh benefits at any time, opioid therapy will be discontinued. We will continually evaluate the benefit/risk ratio of this therapy. *&+-0"./ *( >   >           

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