This example is based on the Blaustein Pain Treatment Center – Johns Hopkins Medicine therapy agreement and should be modified by the practice to suit local circumstances.
[Insert practice name]
PATIENT AGREEMENT FOR BENZODIAZEPINE THERAPY
Benzodiazepines are drugs of dependence. People who take them long term can risk adverse effects including becoming dependent (addicted). Therefore, benzodiazepine prescription is highly regulated. These drugs also have a high potential for misuse and are therefore closely controlled by the local, state and Federal government.
Generally, benzodiazepines are used in the short term for reduction of distressing symptoms (eg anxiety and insomnia). A trial of long-term benzodiazepine therapy may be considered for severe or resistant mental illness.
The purpose of this agreement is to give you information about the benzodiazepine medications prescribed at this practice, and to assure that you and your general practitioner (GP) comply with all relevant regulations.
Your GP’s goal is for you to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on the mutual trust and honesty in the doctor–patient relationship, and full agreement and understanding of the risks and benefits of using potentially addictive drugs to manage your condition.
In signing this agreement, you have agreed to a trial of long-term use of potentially addictive medications as part of your treatment. Because your doctor is prescribing such medication to help manage your condition, it is considered good practice to agree to the conditions outlined below.
My responsibilities as a patient
- I agree to see one doctor at one practice for all my health needs and prescriptions.
- I will have all my medications dispensed at one pharmacy.
- I agree that this medication is prescribed as a trial. If it appears to my doctor that there is no improvement in my daily function or quality of life from the controlled substance, my medication may be discontinued. I will gradually taper my medication as prescribed by my doctor.
- I will inform my doctor of all medications I am taking, including herbal remedies and illicit medication. Medications can interact with drugs of dependence and produce serious side effects.
- I will fully communicate with my doctor to the best of my ability at the initial and all follow-up visits my pain level and functional activity along with any side effects of the medications. This information allows my doctor to adjust my treatment plan accordingly.
- I will not request or accept drugs of dependence from any other doctor or individual while I am receiving such medication from my doctor at the [insert practice name].
- I understand the use of alcohol together with benzodiazepines is contraindicated.
- I will not use any illicit substances (eg cocaine, amphetamines or marijuana) while taking these medications. Use of these substances may result in a change to my treatment plan, including safe discontinuation of my benzodiazepine medications when applicable or complete termination of the doctor–patient relationship.
- If I have a history of alcohol or drug misuse/addiction, I must notify my doctor of such history since treatment with benzodiazepines may increase the possibility of relapse.
- I agree and understand that my doctor reserves the right to perform random or unannounced urine drug testing. If requested to provide a urine sample, I agree to cooperate. If I decide not to provide a urine sample, I understand that my doctor may change my treatment plan, including safe discontinuation of my benzodiazepine medications when applicable or complete termination of the doctor–patient relationship. The presence of a non-prescribed drug(s) or illicit drug(s) in the urine can be grounds for termination of the doctor–patient relationship. Urine drug testing is not forensic testing, but is done for my benefit as a diagnostic tool and in accordance with certain legal and regulatory materials on the use of controlled substances to treat pain.
- I agree to allow my doctor/healthcare provider to contact any healthcare professional, family member, pharmacy, legal authority or regulatory agency to obtain or provide information about my care or actions, if my doctor feels it is necessary.
- I understand my capacity to drive may be affected and I may be asked to cease driving.
- I am responsible for my prescriptions. I understand that lost prescriptions will not be replaced.
- I understand that benzodiazepine prescriptions will not be mailed if I am unable to obtain my prescriptions monthly.
- Repeat prescriptions can be written for a maximum of 1 month supply and will be filled at the same pharmacy.
- Pharmacy: ____________________________ Phone number: ___________________________
- It is my responsibility to schedule appointments for the next benzodiazepine prescription before I leave the clinic or within 3 days of the last clinic visit.
Taking my medications
- I understand that the medication is strictly for my own use. My medication should never be given or sold to others because it may endanger that person’s health and is against the law.
- I am responsible for keeping my medication in a safe and secure place, such as a locked cabinet or safe. I am expected to protect my medications from loss or theft. If my medication is stolen, I will report this to my local police department and obtain a stolen item report. I will then report the stolen medication to my doctor. If my medications are lost, misplaced or stolen my doctor may choose not to replace the medications or to taper and discontinue the medications.
- I am responsible for taking my medications as directed. I agree to take the medication only as prescribed.
- I understand increasing my dose without the close supervision of my doctor could lead to drug overdose, causing severe sedation and respiratory depression and death.
- I understand that decreasing or stopping my medication without the close supervision of my doctor can lead to withdrawal. Withdrawal symptoms can include yawning, sweating, watery eyes, runny nose, anxiety, tremors, aching muscles, hot and cold flashes, ‘goose flesh’, abdominal cramps and diarrhoea. These symptoms can occur 24–48 hours after the last dose and can last up to 3 weeks.
- Any evidence of drug hoarding, acquisition of any benzodiazepine medication or additional drugs of dependence from other doctors (which includes emergency rooms), uncontrolled dose escalation or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the doctor–patient relationship.
Monitoring effects of treatment
- I accept that drug of dependence therapy is only part of my care, and that I must be fully compliant with additional care interventions deemed appropriate for my health.
- I accept that set appointments must be made to review ongoing therapy. This should be monthly and made at the last clinic appointment. No walk-in appointments for medication refills will be granted.
- If an appointment is missed, another appointment will be made as soon as possible. Immediate or emergency appointments will not be granted.
- I will be seen on a regular basis and given prescriptions for enough medication to last from appointment to appointment, and sometimes 2–3 days extra if the prescription ends on a weekend or holiday. This extra medication is not to be used without the explicit permission of the prescribing doctor unless an emergency requires your appointment to be deferred 1 or 2 days.
- It is my responsibility to notify my doctor of any side effects that continue or are severe (eg sedation, confusion). I am also responsible for notifying my doctor immediately if I need to visit another healthcare provider or need to visit an emergency room, or if I become pregnant.
- I understand that during the time that my dose is being adjusted, I will be expected to return to the clinic as instructed by my clinic doctor. After I have been placed on a stable dose, I may receive longer-term therapy from my doctor, but will return to the medical centre for a medical evaluation at least once every 3 months.
- I understand that a reduction of medication will occur if I have deterioration at home or work, or reduction of social activities because of medication, or due to medication side effects.
- I understand that while physical dependence is to be expected after the long-term use of benzodiazepines, any signs of addiction, abuse or misuse shall prompt the need for substance dependence treatment as well as weaning and detoxification from the benzodiazepines.
I understand that cessation of the medication trial, or cessation of the doctor–patient relationship may occur if I display any of the following behaviours:
- presenting to the clinic intoxicated, as assessed by clinical staff
- making any physical threat to any member of staff or other patients
- aggressively complaining about a need for medication
- persistently requesting to have my medication dose increased despite clinical advice
- taking a few extra, unauthorised doses on occasion
- visiting multiple doctors for controlled substances (doctor shopping)
- hoarding medication
- using my medication for non-medical purposes (ie in any other way than prescribed)
- starting frequent unscheduled clinic visits for early refills
- using consistently disruptive behaviour when arriving at the clinic
- obtaining drugs of dependence from family members (including stealing from older relatives)
- having a pattern of lost or stolen prescriptions
- displaying anger or irritability when questioned closely about my symptoms
- being unwilling to consider other medications or non-pharmacologic treatments
- escalating my dose without authorisation
- testing positive for a non-prescribed drug(s) or illicit drug(s) in my urine
- injecting an oral formulation
- forging prescriptions
- selling medications
- refusing diagnostic workup or investigation
- obtaining controlled substance analgesics from illicit sources.
I understand that non-compliance with the above conditions may result in a re-evaluation of my treatment plan and discontinuation of benzodiazepine therapy. I may be gradually taken off these medications, or even discharged from the clinic.
I ______________________________________________ have read the above information or it has been read to me and all my questions regarding treatment with benzodiazepines have been answered to my satisfaction. I hereby give my consent to participate in trial benzodiazepine therapy and acknowledge receipt of this document.
Patient’s signature ______________________________________ Date_______________________
Doctor’s signature_____________________________________ Date_________________________