"Informed Consent for Opioid Prescribed Pills" - Hawaii

Informed Consent for Opioid Prescribed Pills is a legal document that was released by the Hawaii Department of Health - a government authority operating within Hawaii.

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Download "Informed Consent for Opioid Prescribed Pills" - Hawaii

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Informed Consent for Opioid Prescribed Pills
Please review the information listed here. Initial next to each item when you have reviewed it
with your provider and feel you understand and accept what each statement says.
Initial
Statement
My provider is prescribing opioids (pills) for the following condition(s):
_________________________________________________________________
When I take these pills, I may experience side effects that are dangerous. These
include sleepiness, constipation, nausea, itching, or allergic reactions. The pills
may cause me to not think clearly, may slow my reactions, or slow my breathing.
When I take these pills, it may not be safe for me to drive, operate machinery, or
take care of people. If I feel sleepy, confused, or impaired by these pills or other
drugs, I should not do things that may harm others.
If I take these pills regularly, I will become dependent on them. This means my
body will become used to taking the pills every day. I will feel sick if I stop
taking them. I will feel sick if I stop taking them too quickly. I will feel like I
have the flu. I may also have abdominal pain, nausea, vomiting, diarrhea, or
sweating. I may also have body aches, muscle cramps, a runny nose, yawning,
anxiety, and sleep problems.
I may become addicted to the pills. I may need addiction treatment. I will tell my
provider if I cannot control how I am using them. I will tell my provider if bad
things happen because of the pills.
Anyone can become addicted to the pills. People who have had mental illness or
drug or alcohol problems are at higher risk. People who have a hard time
stopping smoking are at higher risk. I told my provider if I or anyone in my
family has had these types of problems.
Taking too many of my pills can cause me to overdose. I may stop breathing. So,
I will not take more than prescribed.
Mixing my pills with psychiatric medicine can cause me to overdose and stop
breathing. I have told my provider about any drugs I take for psychiatric
problems.
Mixing my pills with other drugs that cause sleepiness could cause me to
overdose and stop breathing. I have told my provider about any drugs I take to
help me sleep.
Taking drugs used to treat addiction may reverse the effects of my pills and could
cause me to go into withdrawal. I have told my provider about any drugs I take
1
for drug addiction.
Informed Consent for Opioid Prescribed Pills
Please review the information listed here. Initial next to each item when you have reviewed it
with your provider and feel you understand and accept what each statement says.
Initial
Statement
My provider is prescribing opioids (pills) for the following condition(s):
_________________________________________________________________
When I take these pills, I may experience side effects that are dangerous. These
include sleepiness, constipation, nausea, itching, or allergic reactions. The pills
may cause me to not think clearly, may slow my reactions, or slow my breathing.
When I take these pills, it may not be safe for me to drive, operate machinery, or
take care of people. If I feel sleepy, confused, or impaired by these pills or other
drugs, I should not do things that may harm others.
If I take these pills regularly, I will become dependent on them. This means my
body will become used to taking the pills every day. I will feel sick if I stop
taking them. I will feel sick if I stop taking them too quickly. I will feel like I
have the flu. I may also have abdominal pain, nausea, vomiting, diarrhea, or
sweating. I may also have body aches, muscle cramps, a runny nose, yawning,
anxiety, and sleep problems.
I may become addicted to the pills. I may need addiction treatment. I will tell my
provider if I cannot control how I am using them. I will tell my provider if bad
things happen because of the pills.
Anyone can become addicted to the pills. People who have had mental illness or
drug or alcohol problems are at higher risk. People who have a hard time
stopping smoking are at higher risk. I told my provider if I or anyone in my
family has had these types of problems.
Taking too many of my pills can cause me to overdose. I may stop breathing. So,
I will not take more than prescribed.
Mixing my pills with psychiatric medicine can cause me to overdose and stop
breathing. I have told my provider about any drugs I take for psychiatric
problems.
Mixing my pills with other drugs that cause sleepiness could cause me to
overdose and stop breathing. I have told my provider about any drugs I take to
help me sleep.
Taking drugs used to treat addiction may reverse the effects of my pills and could
cause me to go into withdrawal. I have told my provider about any drugs I take
1
for drug addiction.
It is my responsibility to tell any provider that is treating me that I am taking
opioid pain pills. This is so they do not give me medicines that interact with my
pain medicine.
I have talked about the possible risks and benefits of taking opioid pain pills with
my provider. We discussed the possibility of other treatments that do not use
opioids, including:
_________________________________________________________________
These pills are being prescribed to me because other treatments have not
controlled my pain well enough.
These pills may decrease my pain. But they are unlikely to take away all my pain.
I will take these pills to improve my ability to work and meet other goals I have
discussed with my provider. If these pills do not help me meet those goals, they
will be stopped.
I will store these pills safely. I will keep them where others cannot see or access
them (like in a locked box).
For Men: Taking these pills for a long time may cause low testosterone levels
and affect sexual function.
For Women: I will tell my provider immediately if I think I am pregnant or want
to get pregnant. If I become pregnant while taking these pills and continue to take
them during pregnancy, the baby will be dependent on the pills at birth and may
require withdrawal treatment.
Naloxone is a drug that can reverse the effects of an overdose in an emergency.
My provider can write a prescription for me to obtain Naloxone. I understand that
my insurance may not cover this. I can find more information about Naloxone at
www.getnaloxonenow.org.
I have read this form with my provider and had the chance to ask questions. I understand each
statement written here and, by signing, give consent for the treatment of my pain condition with
opioid pain pills.
__________________________ ____________________________
____________
Patient signature
Patient name printed
Date
__________________________
____________________________
____________
Provider signature
Provider name printed
Date
1
These drugs include buprenorphine (Suboxone® and Subutex®), naltrexone (ReVia®), nalbuphine (Nubain®),
pentazocine (Talwin®), or butorphanol (Stadol®).
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