CONTROLLED SUBSTANCE AGREEMENT AND INFORMED CONSENT
The following agreement relates to my use of controlled substances as part
of a pain treatment plan prescribed by Marquis de Sade Pain Management Incorporated
(MSPMI). The goal of pain treatment is to improve my ability to work and function while
reducing my pain. My doctor will treat my pain with opioids (morphine-like pain killers) and other treatments. Since opioids are
not effective for everyone, my doctor may decide to stop prescribing them for me if I am not improving, or if I can not take them responsibly. If the
treatment is successful, ongoing care, including management of prescription pain killers may be transferred to my primary care physician if necessary.
1. I have been informed about the potential for addiction to controlled substances. If this happens, I will follow my doctor's guidance and
participate in an addiction treatment program if prescribed.
2. I understand some patients develop tolerance to pain medications, and may need to increase their dose over time or change to a different narcotic to
achieve the same pain relieving effect.
3. I UNDERSTAND THAT DISCONTINUING CONTROLLED SUBSTANCES ABRUPTLY MAY BE DANGEROUS AND LEAD TO WITHDRAWAL SYMPTOMS, such as seizures, cramps, sweats,
chills and aches. I must not decrease or stop my medications without medical supervision. I will promptly notify MSPMI if I am unable to take my pain
medication for more than 24 hours.
4. I understand that many medications, especially controlled substances, can interfere with my ability to drive, perform intricate tasks and make
important decisions. I understand that I should refrain from driving and other dangerous or important tasks while starting or adjusting my
medication. If the manufacturer of my medication(s) recommends against operating heavy machinery, MSPMI will assume no liability if I decide to do so. I AM AWARE THAT I COULD BE CHARGED WITH "DRIVING UNDER THE INFLUENCE"
(DUI) AT ANY TIME FOR DRIVING WHEN TAKING CONTROLLED SUBSTANCES.
5. I understand that many medications, including opioids, may harm a developing fetus. I will notify MSPMI as soon as possible if I become
6. I will adhere to the following rules:
> I will use only one pharmacy to fill my controlled substance pain medications.
> I will accept generic substitutes when available.
> I WILL NOT ADJUST MY MEDICATIONS WITHOUT PRIOR APPROVAL FROM MSPMI
> I will not accept prescriptions for controlled substances (pain killers or
sedatives) from other doctors without prior approval from MSPMI.
> I will not use illegal drugs and must limit my alcohol use. My doctor will periodically ask for a urine sample to check for illegal drugs, alcohol,and other pain killers.
> If a specific medication does not work for me I will return the unused portion to MSPMI.
> I will keep my medications away from children and others. MSPMI are not responsible for harm caused to another person who takes my medication.
7. Stolen and lost prescriptions/medications will be replaced only ONCE. I WILL PROTECT THEM FROM THEFT AND ACCIDENTAL DESTRUCTION. A POLICE REPORT IS
REQUIRED FOR ALL THEFTS.
8. I will not hold any owner or employee of MSPMI liable for problems caused by my noncompliance in using controlled substances.
9. I understand that if I develop another pain condition (toothache, abdominal pain, etc.) this does not allow me to self-increase my
medications. I will see my local doctor, disclose all medications that I am taking from MSPMI that I have been ordered prior to taking them.
10. I agree to submit to a urine and/or blood screen to document appropriate blood levels of prescription analgesics and to detect the use of non
prescribed medications at any time.
** I UNDERSTAND THAT I WILL BE DISCHARGED FROM MARQUIS de SADE PAIN MANAGEMENT INC FOR ANY POSITIVE
RESULTS FOR ILLEGAL DRUGS, FOR A URINE SAMPLE THAT HAS A TEMPERATURE READING OF BELOW 90 DEGREES, FOR REFUSING TO
GIVE A URINE SAMPLE WHEN REQUESTED OR FOR NOT SHOWING UP AT A DESIGNATED OFF SITE LAB IN THE ALLOTTED TIME I AM GIVEN TO ARRIVE THERE.
11. I recognize that therapy with controlled substances is just one part of my treatment. Other treatments, including mental health evaluation may be
appropriate for me. I agree to follow the treatment recommendations of my pain doctor including getting exercise, tests, consultations, physical and
mental health treatments.
12. Prescription for controlled substances are issued only during appointment which must occur at least monthly. I will not receive new
prescriptions if I do not keep my appointments.
13. I understand that MSPMI office hours are Monday through Friday, 8:30 am to 4:30 pm, excluding lunch hours from 12:00 pm until 1 pm and holidays. THE
DOCTOR ON CALL MAY BE REACHED AT OTHER TIMES FOR EMERGENCIES ONLY! I WILL NOT REQUEST MEDICATIONS AFTER HOURS. I WILL SCHEDULE AN APPOINTMENT WELL
BEFORE MY MEDICATION RUNS OUT.
14. The following are grounds for discharge from MSPMI:
> Altering or forging a prescription. This is a felony and will be reported.
> Lying to MSPMI about anything concerning my medical care.
> Multiple missed appointments, late cancellations, or late appearances.
> Repeated violations of this agreement.
> Failure to appear or to produce urine for a random drug screening.
> Persistence non compliance with my pain treatment plan.
> Use of illegal drugs or substances
> Disruptive, threatening or violent behavior.
15. I authorize a copy of this to be sent to my pharmacy.
16. I authorize a copy of this agreement to be sent to my Primary Care
Primary Care Physician signature:
MSPMI Medical Staff signature:
MSPMI Physician signature:
Pain Contracts; Are
They a Legitimate Agreement or Just Institutionalized Coercion?