Salvage Psychiatry-Benzodiazepine and Stimulant Agreement

My provider may agree to prescribe benzodiazepine (like Klonopin, Xanax or Ativan), stimulants and hypnotics to control the symptoms of my psychiatric illness (or manage a side effect from a primary medication) and to help me function better in my life.

I understand the following about benzodiazepine medications:

• If I use a Benzodiazepine daily, they will become less effective over time This is a TEMPORARY treatment

• I could suffer withdrawal symptoms if I stop a benzodiazepine suddenly.

• Benzodiazepine withdrawal can be deadly in some cases

• There is a risk of addiction with benzodiazepine use

• Benzodiazepines have multiple long-term side effects, including memory disturbance and increased risk for Alzheimer's Disease

These medications are often abused and are extremely dangerous when used improperly. For this reason, and others, I agree to the following rules regarding my use of medications:

• I will take medications at the dose prescribed by my provider

• I will take medications at the frequency prescribed by my provider

• I will not change how I take these medications without the prior approval of my provider

• I will not request early refills

•  Lost or stolen medications will not be replaced; I am responsible for my  medications               

• I will arrange for refills at the prescribed interval only during clinical hours

•  All prescriptions will be written, at maximum, on a 28-day schedule unless otherwise noted

•  I will not request these types of medications from ANY other providers without the approval of my OTC approval

•  I will keep my medication list updated and current with Salvage Psychiatry

•  I will keep appointments with my psychiatric provider at Salvage Psychiatry

•  I will not receive any controlled substance prescriptions, if I am currently prescribed any other controlled substances.

•  I will not receive controlled substances if I have a previous substance abuse history.

•  I am required to actively participate in the treatment plan as described by my provider, this could include groups and/or one on one therapy

•  I agree that I will not use illicit marijuana, alcohol or other illicit substances while taking this medication

• I agree that I may be subject to random urine drug screens and pill counts

• I understand that if my urine drug screen indicates that I am not taking these medications my provider will stop these medications

•  I understand that if my pill count suggests that I am taking the medication differently than prescribed my provider will stop these medications.

• I will not sell, trade or give my prescription medication to anyone.

• I will keep these medications away from children

• I understand that failure to comply with the above may cause my provider to STOP prescribing these medications

• I understand that if I do not show improvement in symptoms that my provider will stop prescribing these medications

• I understand that while being prescribed this medication, currently lab work and EKG may be requested.

• I understand that my provider may stop these medications if I show significant side effects from these medications or demonstrate a problematic tolerance.

• If my provider stops prescribing me benzodiazepines, they will stop them in the safest manner possible

• I agree that my dose might NOT be increased and could be tapered then discontinued.

 

I have read this agreement and agree to all terms as outlined above.

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