Pain and Addiction. Steven M. Benecke, M.D. Academic Pain Physicians of Colorado Springs April 18, 2008. Crossroads. Crossroads. Do no harm Cannot always correct the condition causing pain. Paradigm shift in treatment:. Pain has become the “fifth” vital sign Specialty of pain management
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Personal history of substance abuse
Age (mark box if between 16-45)
History of preadolescent sexual abuse
Psychological disease (ADD, OCD, bipolar, schizophrenia,
0-3: low risk (6%)
4-7: moderate risk (28%)
≥8: high risk (>90%)
1 1ORTWebster & Webster, Pain Med. 2005;6:432.
Patient Name: __________________________
This letter serves to confirm that you and Dr. Benecke have come to a mutual agreement that all other modalities of pain management have been exhausted and because of persistent pain, it has been mutually agreed upon to begin opioids. You and your care giver agree to:
You acknowledge that you have no prior history of substance misuse (alcohol/ recreational drugs).
Only Dr. Benecke will prescribe analgesics for you.
You will adhere to the medications’ prescribed schedule and not increase the number of pills or their frequency without being directed to.
Only one pharmacy will fill these prescriptions and you will include that pharmacy’s address and number to be included with this document and will allow this document to be shared with them.
Your primary care physician as well as all treating physicians will be made aware of this agreement.
Prescriptions or medications that are lost or stolen will not be replaced.
You agree to random drug testing and will comply when requested to bring your pills with you for a random pill count.
If the medications are continued for more than six months, you will agree to see a pain psychologist as part of the therapy for your pain condition.
Violation of any of these will lead to a termination of the relationship and an immediate cessation of the medications with a referral to an appropriate detoxification center.
It must be understood that there are risks and uncertainty to the long-term use of these medications. Risks include psychological dependency (addiction), sedation, slowing of your respirations, nausea, itching, and constipation. Abrupt withdrawal of these medications, will lead to abstinence syndrome (increased heart rate, sweating, diarrhea, nausea, vomiting). Long term effects are not known and these drugs should not be taken when pregnant or if the possibility of pregnancy exists. You are responsible for keeping these medications from children and other adults. Determining if it is safe to drive or work while consuming these medications is your responsibility. Consuming opioids during pregnancy will lead to physical dependence in the new born.
These medications must be refilled in person at your monthly appointment.
Your signature recognizes the seriousness of your voluntary decision to participate in the use of opioids for your pain condition. Honest communication between everyone will ensure your success and continued health.
Date:_____________ Signature of Patient:______________________________________