PATIENT OPIOID CONTRACT

( REQUIRED FOR ALL PAIN MANAGEMENT PATIENTS )

If on a controlled / narcotic medication regimen, you must be seen every 30 DAYS or no earlier than every 28-29 days by the physician at Tysons Pain Center ,P.C., for re-evaluation of your condition and treatment plan. EARLY REFILLS ARE NOT PERMITTED FOR ANY REASON.

You must have an appointment in order to be treated. Walk-in visits are not permitted. It is your responsibility to make an appointment in advance.

You will obtain opioid pain medication prescriptions only from one physician per National Opioid prescribing guidelines to avoid possible over-dosage or misuse of controlled medication.

You will NOT receive other controlled medications such as sleeping pills / sedatives, stimulants from other physicians without authorization and/or knowledge from Dr. Nagia. M.D. This is to ensure your health and safety & reduce risk of possible over-dosage.

You will take your medication exactly as prescribed. You will not take more medication per day at your own discretion.

If you lose or misplace your prescription or medication, you must report this to the police per DEA requirements, and provide Dr. Nagia with a copy of the report including the officer’s contact information and case number. It is your responsibility to secure your medication.

You will be provided a prescription only during regular office hours (Mon-Thurs. 10:00am-4:00pm) at your scheduled appointment with your physician.

You will not share or sell your prescription / narcotic medication per Federal Law / DEA regulations. This is a felony with a minimum 10 year prison sentence.

As a chronic pain patient, you agree to random medication counts of your unused pain medication upon the request of your physician, per pain management guidelines. Failure to comply will result in termination of care.

As a chronic pain patient, you agree to random urine or blood specimen at least twice per year upon your physician’s request for evaluation of your treatment regimen & compliance, per pain management guideline & DEA regulations. Failure to comply will result in termination of care.

You understand that your doctor will gradually decrease your opioid medication if you do not follow the above plan, or if your doctor believes the opioids are not helping or are harming you.

Your opioid medication will be continued if there is demonstrated improvement in your pain level and function as determined by your doctor. If all treatment measures recommended by Dr. Nagia, M.D. have been exhausted, and your condition(s) show no meaningful improvement, you will be discharged and referred to another facility that will better control your condition(s).

Important Information to know in case you are prescribed a controlled medication:

Risk To Unborn Children

If you become pregnant, you will stop all medications and notify Dr. Nagia as soon as pregnancy exists in order to protect the health of your unborn child, and modify your treatment. Children born to women who are regularly taking opioids will likely be physically dependent at birth. Women of childbearing age should maintain safe and effective birth control while on opioid therapy.

Opioids

You have agreed to a trial of opioid (narcotic) treatment for your pain. Opioids include medications such as Percocet, Oxycodone, Morphine, or any other controlled medications on a certain medication schedule. The purpose of this treatment is to reduce your pain and to improve your level of function at work at home and/or other valued activities. Alternative therapies have been explained and offered to you. You and your doctor have elected a trial of opioid therapy as one component of treatment. It is important that you be aware of the potential risks and side effects of these medications. Common issues are discussed below.

Physical Side Effects

Possible side effects include mood changes, drowsiness, dizziness, constipation, nausea and/or confusion. Many of these side effects, if they occur, gradually resolve over days to weeks. Constipation often persists and may require management with medications. If other side effects persist, trials of alternative opioids may be necessary or opioids may need to be discontinued. You should not drive a care or other vehicle or operate machinery while your dose is being increased or if the medication makes you drowsy. The sedating effects of alcohol and other sedatives are additive with the side effects of opioids. It is strongly advised patients avoid alcohol while receiving opioid therapy.

Physical Dependence

Physical dependence is an expected side effect of long-term use of opioids if they are prescribed on a daily basis. This means that if you take opioids continuously and stop them abruptly for any reason, you will experience a withdrawal syndrome. This syndrome often includes sweating, diarrhea, irritability, sleeplessness, runny nose, tearing, muscle and bone aching, and dilated pupils. To prevent these symptoms, medications must be taken regularly if physical dependence is present. When opioids are discontinued, they should be tapered under the supervision of your physician. Do not abruptly stop taking your prescription without consulting your physician.

Addiction

Addiction is present when an individual experiences loss of control over the use of medications, is constantly seeking drugs, and/or experiences adverse consequences as a result of drug use yet continues to take the medication. Most patients who use opioids are able to take medications as prescribed on a scheduled basis. They do not seek other drugs when their pain is controlled, and experience improvement in the quality of life as a result of the opioid medications; thus, they are NOT addicted. Physical dependence does NOT indicate addiction. Individuals with a history of alcoholism or other drug addiction may be at increased risk for the development of addiction while using opioids, and are not suitable candidates for a controlled medication regimen to tret chronic pain.

Tolerance to Medication

Tolerance to the pain-killing effects of opioid medications is possible with continuous use. This means that although there has been no physical change in the underlying condition, an increased dose of medication is required to achieve the same level of pain control experienced when the medications were initiated. We do not fully understand why, or understand under what conditions, tolerance to the pain-killing effects of opioids occurs. When it does occur, it may require tapering and discontinuation of the medication. Sometimes tolerance can be handled by substituting a different opioid medication.

Failure to comply with this opioid contract will result in the TERMINATION of your pain management care by our facility, whereas no more appointments or prescriptions will be provided for you.