DRUG POLICY Neurosurgical Solutions, PA

1. Patients should call during business hours Monday-Thursday only for their refills, not after regular business hours.

2. Do not run out of medication before calling for refills. Call 2-3 days before your medications run out (Monday - Thursday).

3. Do not take more medication than prescribed. Not only will you run out of medication early, but also you may not be allowed further medications since you over-used.

4. We prefer you get your medications from a single pharmacy. If you have a pattern of skipping pharmacy-to-pharmacy, we may choose to stop providing medications. Using a single pharmacy allows us to more safely keep track of your medications.

5. If you commit violent crimes, theft, or other significant legal violations, we may discontinue providing controlled substances for your chronic pain. You must avoid even the appearance of such inappropriate behavior.
For instance, if found driving intoxicated, convicted of larceny, etc., ... we may discontinue providing controlled substances for your chronic pain. Patients prescribed controlled substances must be dependable as well as obey rules and laws.

6. Driving: You may technically be under the influence if you drive after having taken medications given for your chronic pain. You could suffer the consequences of this the same as driving drunk.

7. You may not give your medications to anyone else.

8. We will work with your other doctors to provide appropriate chronic pain medications as long as you act responsibly; coordinating which doctor prescribes certain types of medications.
For example, we may provide narcotics, while asking/allowing your family physician to provide anxiolytics or muscle relaxers (i.e. valium). In some/many instances, we will clearly state we wish to be the sole supplier of a certain medications. In such instances, you are not allowed to get any such medication from anyone else without our prior written approval. We hold you just as obligated to follow our rules as if you had actually signed a drug contract. Allowing us to provide you with medical care obligates you to our rules.

9. Medications will not be refilled early. If your medications are lost, stolen, thrown away by an angry friend or spouse, flushed, beamed up by aliens, etc. they will not be filled early. NO EXCEPTIONS. Therefore, don't even ask.

10. We may ask for random drug testing to prove no illicit drug use occurs. If you decline, we will discontinue providing controlled substances for your chronic pain.

11. You must fully explain any prior or current drug dependencies or abuse histories at or before the first occasion for us to provide prescriptions for controlled substances. If you do not, we will discontinue providing controlled substances for your chronic pain considering you to have intentionally concealed valuable medical information violating our physician-patient relationship.

12. By accepting prescriptions for controlled substances, you agree that other reasonable forms of treatment have not been effective or have produced too many side effects.

13. Violating any of these rules is not only a disservice to yourself, but destroys our trust in you. Having accepted our medical care serves as implied and implicit permission to share information with your other health care providers as it pertains to your use of medications and related behaviors.

14. You implicitly give us permission to discuss your past medication and present histories with pharmacies.

15. We will protect your medication rights and ensure no one but you or your designated representative picks up your prescription at our office. We require photo ID for all controlled substance prescription pick-ups. Such Photo ID must be someone who is both logically your representative (i.e. your spouse) and someone you designate beforehand. Spouses may not expect to pick up a prescription just because they are legally married, the patient must tell us their spouse will pick up the prescription. We reserve the right to refuse dispensing your prescription to anyone other than you. If the pharmacy dispenses your medication to someone other than you (i.e. technically someone obtains your prescription illegally), we will not refill early and we will mandate you file a police report against that event.

16. We reserve the privilege to taper your medications as professionally indicated.

17. The presence of this document and subsequent revisions obligates you to our rules, even if you personally have never seen, read, nor heard of this document.

18. If you are a female of childbearing age, you certify that you are not pregnant and that you will take measure to prevent pregnancy during the course of your treatment with controlled substances. If you become pregnant, you will inform us immediately.

19. You agree to keep all your scheduled appointments with us and to fully participate in other services recommended by us, which may include psychological, psychiatric, or physical rehabilitation.

20. Documented improvement in your function may be required to continue use of long-term narcotics. This may include employment or being able to take care of more activities of daily living independently.

21. You understand that disciplinary sanctions (actions) based on these above rules may include (but are not limited to) oral/written warning, counseling, restriction of meds, expulsion from the clinic without referral to another caregiver, referral to appropriate law enforcement agencies for prosecution, and even immediate discontinuation of medication without substitution.

I have read this document and understand it fully. I have had all my questions answered satisfactorily. I fully intend to abide by the conditions set forth by the pain physicians for the administration of opioid therapy and/or other controlled substances. I understand ad have read the potential risks and benefits of opioid therapy. I consent to the use of opioids to help control my pain. I understand that my treatment with opioids will be carried out in accordance with the conditions stated above.