Opiate Consent

Potential Risks, adverse reactions, complications, and medication interactions associated with opioids, including death (but are not limited to the following): allergic reactions, slowing of breathing rate, slowing of reflexes or reaction time, sleepiness, dizziness, and confusion, impaired judgment and inability to operate machines or drive motor vehicles, nausea, vomiting and constipation, itching, physical dependence or tolerance to pain relieving properties of the medication, addiction, changes in sexual function, changes in hormonal levels.

• If a benzodiazepine is taken with an opiate, there is an increased chance of slowing the breathing rate, sleepiness, dizziness, confusion, and impaired judgment.
• Use of opiates poses a particular risk to women who are pregnant or who may become pregnant. If I plan on becoming pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetrician and this office to inform them.

 The following alternatives to prescribed opioids have been explained to me, and I have freely consented to taking opioid medication:

• Acetaminophen
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
• Corticosteroids
• Serotonin and Norepinephrine Reuptake Inhibitors
• Neurostimulators
• Anticonvulsants
• Physical Therapy
• Massage, Acupuncture, Chiropractic Care
• Injections (Nerve, trigger point, Radiofrequency, or epidural injections)
• Exercise

Monitoring for effectiveness will occur with this medication if used for more than 30 calendar days, as follows:

• Frequency of office visits
• Frequency of substance abuse assessment

The undersigned attests that s/he has been informed and understands the risks, benefits, and alternatives of opioid pain medications and their options. I have had a chance to have all my questions regarding this treatment answered to my satisfaction. By signing this form voluntarily, I give my consent for the treatment of my pain with opioid pain medicines.