Pain Management Contract
An example is noted below of this type of pain management contract for narcotic pain medications and/or any other controlled substances:
Pain Management Agreement:
The following agreement is made between
Patient: ____________________________________________________
and Dr. Mark Wolgin
so that there will be no misunderstanding about how the narcotic pain medications are to be used, and to prevent any potential violations of the laws that regulate these medications.
( ) I understand that Dr. Wolgin is a surgeon, and in that role, is looking for treatable causes of pain. If none can be found, or if pain is continuing after the recommended interventions, chronic pain is best handled by a pain management specialist. This agreement is made in the meantime, while you are under the care of Dr. Wolgin for your pain symptoms.
( ) I understand that this agreement is an important element to the trust that is the foundation of the doctor-patient relationship, and that Dr. Wolgin agrees to treat me based on this agreement.
( ) I understand that if I break this agreement, Dr. Wolgin will stop prescribing my pain control medications.
( ) If this agreement is broken, the pain medications will be tapered off over several days to avoid a drug withdrawal reaction. I also recognize that Dr. Wolgin’s office will do what can be done to help arrange a referral to a drug dependence treatment program or pain management specialist, but also recognize that Dr. Wolgin cannot force any other provider to take over my care, and thus cannot guaranty that I will be accepted into a pain program.
( ) I agree that if I am tranferred to a pain management program, under the supervision of a pain management specialist, that that specialist, and not Dr. Wolgin, will be prescribing pain medications. I also agree that if I am accepted to a pain management program, I need to do my best to not be fired from that program, as it becomes very difficult to find another pain specialist once I have been fired from a pain management program.
( ) I agree that if I violate the terms of this agreement, it will be my responsibility to find another pain management specialist.
( ) I am also amenable to accepting treatment for any overlying mental health issues, whether that treatment is with a psychologist or psychiatrist, or other mental health professional. I understand that chronic pain can affect the whole demeanor of a patient, and depression and anxiety issues, when they occur, can magnify the pain experience. These mental health issues, when present, need to be addressed as well.
( ) I will communicate fully with Dr. Wolgin about the nature of my pain, how the pain is affecting my daily life, and how the intensity of the pain is changing with the pain treatments being prescribed. If my pain is worsening, I understand that I may have to come in early for another evaluation, and may have to consider more aggressive treatment options, but if I take more medications than were prescribed, a refill will not be called in early.
( ) I understand that pain medications are an aid to pain relief, and there is no promise that they will relieve all the pain.
( ) I will not use any illegal, controlled substances such as marijuana, cocaine, etc., and the use of alcohol will be infrequent and limited in general, and will not be associated with any use of heavy machinery or with driving a motor vehicle.
( ) I will not share my medication with anyone.
( ) I will not attempt to obtain any other controlled substances (including opiate medicines, anxiety medicines, or stimulants) from any other doctor without first notifying Dr. Wolgin.
( ) I understand that I have to take very good care of my medications, since, if they are lost or stolen, they will not be replaced until it is time for their refill to be given.
( ) I agree that refills will be given only during regular office hours, not after hours or on weekends. Additionally, I agree to call in a few days before the medication supply runs out, as same day prescription refills are not always possible.
( ) I agree that if asked, I will present my remaining medications for a pill count, and will also be available for a random drug screen to assess my compliance with the treatment program. I also understand that if the results suggest that I am not following directions, or if illegal substances are found on drug screening, I risk being discharged from the pain program, and possibly also from the practice.
( ) I authorize Dr. Wolgin and my pharmacy to cooperate fully with any law enforcement agency, whether city, state, or federal, and also including the GA State Board of Pharmacy, for any investigation of possible sale, misuse, or diversion of my pain medicines. I give permission to Dr. Wolgin to provide a copy of this agreement to any requesting pharmacy, emergency physician, or my primary care physician. I agree for these instances where this agreement might be shared, that I waive any applicable doctor-patient privilege or right to privacy or confidentiality with respect to these authorizations.
( ) I agree to follow the above guidelines and my questions have been answered about the issues addressed above. I have received, or I can receive any time I choose, a copy of this document.
Patient:__________________________________________________
Date/Time:______________________________________
Witness:__________________________________________________
