“Being able to be your true self is one of the strongest components of good mental health.”
Lauren Fogel Mersy

CONTROLLED SUBSTANCE POLICY

We are generally inclined to prescribe non-habit-forming medications. A habit-forming medication is often described as a “controlled substance”. Controlled substances are medications which include but are not limited to the following: Certain sleep medications (Ambien, Lunesta, Sonata, etc. and their generics); Benzodiazepines (Xanax, Ativan, Valium, Librium, Klonopin, etc and their generics) (Adderall, Vyvanse, Concerta, Ritalin, modafinil etc. and their generics); and Buprenorphine/Naloxone (Suboxone, Subutex).

Agreement and Informed Consent

I understand and agree to the following:

• Medication(s) for the management of my medical condition will be provided as long as I follow the rules/terms/conditions of this agreement.
• I will disclose to my provider every medication I am taking; this includes over the counter medications, vitamins, and supplements.
• I always have the right to refuse or stop taking my medication(s), but that doing so may result in withdrawal symptoms with potentially severe medical consequences.
• If a controlled substance is prescribed, it may be written for a limited quantity and/or a short duration.
• I will take my medication(s) exactly as prescribed by my provider.
• I am not allowed to change dosage amounts or alter the time schedule of taking the medication without first consulting my prescribing physician.
• If I decide to stop a medication or decrease my dose without direct supervision from my provider, he/she is not responsible for any serious adverse reactions or consequences I may experience, including seizures or death.
• Any medical treatment is a trial, and that continued prescription is contingent on evidence of benefit and improved functionality.
• If a controlled substance is prescribed, a 90-day supply may not be provided.
• Controlled substances can be habit forming and can put me at risk for developing physiological dependence, tolerance and withdrawal.
• I agree to submit to urine or oral fluid drug screens to detect the use of illegal substances, non-prescribed, and prescribed medications at any time and without 24-hour notice as ordered by my provider.
• Controlled substances may impair my alertness, cognitive ability, and reaction times.
• I will exercise extreme caution when taking controlled substances and driving or operating heavy machinery.
• I am aware that I could be charged with DUI or cause injury to myself or others if I choose to drive a vehicle while on controlled substances.
• I will not combine controlled substances with the consumption of alcohol or other illegal drugs.
• If there is concern for medication abuse, diversion (giving or selling the medication to others) or “doctor shopping” (obtaining similar medications from multiple prescribers), my care will be terminated at my provider’s discretion.
• My provider has the right to contact proper authorities (such as the police, DEA etc.) if there is concern that this is occurring.
• If responsible legal authorities have questions concerning my treatment, all confidentiality is waived, and these authorities may be given full access to my records for their investigation.
• An appointment will be required for all refill requests I make.
• Controlled substances will not be phoned in after business hours, on weekends or holidays.
• At least 24 hours for prescription refills authorization is needed and that requests received after 3:00pm are handled the next business day.
• I will keep my medication(s) locked in a safe place and will not share it with others.
• Lost or stolen medications or prescriptions will only be replaced once, providing that I have a police report.
• When refills are due, I will contact my provider at least one week prior to running out.
• Any missed appointment may constitute treatment failure and discontinuation of my medication and/or discharge from Wilmington Mental Health.
• My prescribing physician has permission to discuss medication details with my dispensing pharmacy and/or current and previous healthcare professionals at their discretion.
• My prescribing physician will routinely access the Prescription Monitoring Program (PMP) to confirm controlled prescription medications I have purchased and which pharmacy they were purchased from.
• If I am having withdrawal symptoms due to lost or stolen controlled prescriptions, I am responsible for going immediately to the ER or calling 911 to seek immediate medical attention.

General Guidelines

An initial face-to-face appointment and in-office visit every 90 days at a minimum may be required for all prescriptions of controlled medications. Wilmington Mental Health will not make exceptions to local or federal regulations. In addition, all patients participating in controlled substance psychiatry program must attend behavioral or psychological treatment at least once a month during or prior to scheduling an appointment with a psychiatrist.

We encourage you to call our office if you are experiencing adverse effects from a medication which does not constitute a medical or psychiatric emergency, but which you would like to discuss promptly. We do not prescribe benzodiazepines on a long-term basis. All benzodiazepines are classified by the FDA as controlled substances due to their potential for abuse and dependence. We do not prescribe benzodiazepines to patients who are taking daily opiate pain medication. We prescribe stimulant medications when appropriate diagnostic testing has previously been done and available for review, and the patient agrees that the potential benefits outweigh the potential risks. Stimulants are a class of medications which are commonly prescribed for ADHD (and occasionally for other disorders).

Female Patients

Patients who become pregnant are required to notify their provider immediately and understand this may result in tapering their controlled medications for the safety of the fetus. I understand that controlled substances can have adverse effects on a pregnancy and agree to inform my provider if I become pregnant, if I am planning to become pregnant, or believe I may be pregnant.

Termination

Failure to comply with this policy will result in the discontinuation of the medication(s) and/or termination from my provider’s care. I understand that I will be terminated from my treatment if I alter or forge a prescription, which is a felony and will be reported. I further understand that if I violate this contract, Wilmington Mental Health will contact me by phone and in writing that I will be discharged or have my care transferred.

I acknowledge the risks and potential benefits of treatment with controlled substances have been explained and I have had the opportunity to ask questions I may have. I also affirm I have the full right and power to sign and be bound by this agreement. I have read, understand, and accept all the terms in this agreement.

THE HOLMES-RAHE LIFE STRESS INVENTORY

The Social Readjustment Rating Scale

Instructions: Mark down the point value of each of these life events that has happened to you during the previous year. Total these associated points. There are no right or wrong answers. The aim is to identify which of these events you have experienced lately.

MOOD DISORDER QUESTIONNAIRE (MDQ)

Instructions: Please answer each question as best you can.

1. Has there ever been a period of time when you were not your usual self and…