Controlled Substance Agreement
I understand that controlled prescriptions are monitored and regulated by state agencies and agree to:
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No Sharing, No Early Refills. I will not overuse or share the medicine and understand that it cannot be refilled early, even if the pills are lost.
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Only Receive and Change Controlled Prescriptions at Scheduled Visits. I will keep regular visits and understand that I can only receive refills for controlled prescriptions at these visits. If I think I need to increase or change a controlled prescription, I will schedule an office visit rather than trying to make changes on my own.
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Urine Drug Screening. I understand that my provider may require random urine drug screening. Controlled substances will show up on urine drug screens.
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Do Not Obtain From Other Providers. I will not fill prescriptions from other providers for the same category of controlled substance without alerting my current provider first (unless it is part of a hospital stay). If taking benzodiazepines, I will not fill prescriptions for opioid pain medications without notifying my provider. I understand that combining benzodiazepines with alcohol or opioids is a common cause of death.
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Refill Limitations. I understand that in New York, I have to be seen for every 30-day prescription per state regulation.
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Pharmacy Regulations. The pharmacy requires that the person picking up the medicine show a government-issued photo ID. I understand that I may designate someone else to pick up the prescription.
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Out-of-State Pharmacies. I understand that most states will not honor out-of-state prescriptions for controlled substances.
Examples of Controlled Substances
Benzodiazepines: alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clobazam (Onfi), clorazepate (Tranxene), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), oxazepam (Serax), quazepam (Doral), temazepam (Restoril).
Stimulants: methylphenidate (Ritalin, Concerta, Methylin, Metadate, Aptensio, Adhansia, QuilliChew, Quillivant, Cotempla, Daytrana, Jornay, Azstarys), dexmethylphenidate (Focalin), amphetamines (Adderall, Adzenys, Dyanavel, Mydayis, Evekeo), dextroamphetamine (Dexedrine, Xelstrym, Zenzedi, Vyvanse).
Sleep Medicines: eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien, Edluar, Intermezzo), daridorexant (Quviviq), lemborexant (Dayvigo), and suvorexant (Belsomra).
Opioids: buprenorphine, codeine, hydrocodone, hydromorphone, fentanyl, meperidine, morphine, tramadol, oxycodone, and OxyContin.
Other: modafinil (Provigil, Nuvigil), pregabalin (Lyrica), dronabinol (Marinol), gamma hydroxybutyric acid (Xyrem), and barbiturates.
