ABH CONTROLLED SUBSTANCE AGREEMENT

Controlled substances (benzodiazepines, amphetamines, buprenorphine, etc.) are very useful, but have a high potential for misuse and are, therefore, closely controlled by our local, state, and federal government. As a patient of Astra Behavioral Health, LLC, before receiving medications listed as Controlled Substances, it is required that you agree and understand the following notices and policies.

Please carefully read the information below.

PATIENT NAME* This field is required.

First Name

Last Name

I agree to take my medication as prescribed and not alter the way I take my medication without consulting my prescriber.* This field is required.

YES

I agree to inform my Astra Behavioral Health, LLC provider of all medications prescribed by other providers, and all non-prescription medications I am taking during my Initial Evaluation.* This field is required.

YES

I agree not to obtain medications from another physician, nurse practitioner, hospital, dentist, pharmacy, or any other sources without discussing with my prescriber beforehand.* This field is required.

YES

I agree that I have been provided with information regarding the potential side effects of the specific controlled substance prescribed to me, and agree to notify my provider if I experience one or more symptoms while taking the medication.* This field is required.

YES

I agree to obtain lab work as ordered by my Astra Behavioral Health, LLC provider to include labs related to my treatment. I agree to seek medical clearance to allow controlled substance medication management, should there be any abnormal lab results.* This field is required.

YES

I agree that I will not operate a motor vehicle, or heavy machinery, during either my first days of taking the prescribed controlled substance medication, or after a dosage increase to ensure my tolerance of the medication does not cause side effects of drowsiness or lethargy.* This field is required.

YES

I agree to not sell, share, or give my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.* This field is required.

YES

I have been informed that my prescription must be protected from theft or unauthorized use. I have been informed that if I report my medication has been lost or stolen, my prescriber will not be expected to provide a replacement. If there has been a theft of my medication, I will report this to authorities and bring a copy of the police report to my next appointment.* This field is required.

YES

I agree to not conduct any illegal or disruptive activities in or around property owned/operated by Astra Behavioral Health LLC and to treat all office staff with respect. I agree that should such behavior occur, including rude or disrespectful comments; I will be terminated from treatment without recourse for appeal and the appropriate authorities will be notified.* This field is required.

YES

I agree to abstain from benzodiazepine medications, alcohol, opiates, stimulants, and other addictive substances while being prescribed buprenorphine, or any controlled substances, and I understand that my prescriber may terminate my treatment if I violate this term of the treatment agreement.* This field is required.

YES

I agree that I will be open and honest with my Astra Behavioral Health, LLC provider, and treatment team and will inform my provider and therapist about cravings or unhealthy situations in which I am involved, specifically regarding any misuse of my prescribed medications and/or relapse, that has occurred before a drug screening confirms it.* This field is required.

YES

I agree to comply with urine drug screening and pill counts at every appointment, thereby, documenting the proper use of any medication. If alcohol abuse is suspected, a breathalyzer or blood alcohol level may be ordered. Unannounced urine or serum toxicology specimens may be requested and my cooperation is required.* This field is required.

YES

I agree to comply with random drug testing required within 24 hours of my provider’s request. I understand that if this office is unable to reach me for notification of a random screening, I may be discharged without further notice. Therefore, I agree to immediately notify this office of any change of address and/or phone number.

YES

I agree that I will be subject to drug screens. I understand that when performing a urine drug screen, a staff member may witness me if suspected of altering my urine sample, or misusing my medication. I also understand that attempts to alter my urine or providing a sample other than my own may result in termination from treatment without recourse for appeal.* This field is required.

YES

I understand that Astra Behavioral Health, LLC will use the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system to monitor my prescription history on a regular basis.* This field is required.

YES

I have been given a copy of clinic procedures, including hours of operation, the clinic phone number, and responsibilities to me as a recipient of controlled substance medications and treatment services at Astra Behavioral Health, LLC.* This field is required.

YES

I understand that if I violate any of the above conditions, my prescription for controlled medications may be terminated. If the violation involves obtaining these medications from another individual, or the concomitant use of non-prescription illicit drugs, I may also be reported to other providers, pharmacies, medical facilities and appropriate authorities.* This field is required.

YES

Benzodiazepines are prescription drugs used to treat conditions like Anxiety, Insomnia, and seizures. Examples of these drugs include: Alprazolam, Clonazepam, Diazepam, and Lorazepam. The FDA has applied a Black Box Warning (an alert for consumers) that the use of opioids and benzodiazepines together has serious risks that include unusual dizziness/lightheadedness, extreme sleepiness, slowed or difficulty breathing, coma and death. Alcohol increases these risks. It is Astra Behavioral Health, LLC policy to NOT prescribe benzodiazepines to patients who also use opioids. If a patient is already prescribed both, the prescriber has a responsibility to taper the benzodiazepines as part of the treatment plan. These patients must be monitored at appropriate intervals and visits may be more frequent.

Buprenorphine (Suboxone or Sublocade) are medications used in combination with naloxone to treat opioid addiction. Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, methadone, and many others. Buprenorphine is an opioid analgesic medication, while naloxone is an opioid antagonist drug, and the two are combined in a 4 to 1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication. Injection of buprenorphine/naloxone by a person who is addicted to opioids will produce severe opioid withdrawal.

I understand that combining buprenorphine with benzodiazepine medications (Valium, Klonopin, Ativan, Xanax, Librium, Serax, etc.), alcohol, and other sedating drugs have been associated with severe adverse side effects, including death.* This field is required.

YES

PATIENT SIGNATURE* This field is required.I have been fully informed of the above treatment agreement points and have full understanding of my duties as a patient of Astra Behavioral Health, LLC in regards to the controlled substances I may be prescribed.

Clear

TODAYS DATE* This field is required.

Date

Please verify that you are human* This field is required.We do not accept robots into our Medication Assisted Treatment program.