The following agreement relates to my use of controlled substances prescribed for chronic pain prescribed by a physician at the Pain Management Center at Brigham and Women's Hospital. I recognize that specific policies regarding the use of controlled substances are followed by the staff at the Pain Management Center. I will be provided with controlled substances while actively participating in this program only if I adhere to the following regulations:

1. I will use the substances only within the parameters given by the Pain Management Center physician.

2. I will not receive replacements for lost or stolen medications.

3. I will receive controlled substances only from the Brigham and Women's pain staff. My violation of this will result in a discontinuation of treatment.

4. I will not expect to receive additional medication before my next scheduled refill, even if my prescription runs out.

5. I will accept generic brands of my prescription medication.

6. If it appears to the physician that my daily functioning and quality of life are not benefiting from treatment with the controlled substance, I will gradually taper my medication as prescribed by the physician. I will not hold any member of the Pain Management Center liable for problems caused by discontinuance of controlled substances, provided that I receive 30 days notice of termination.

7. I agree to submit to urine and blood screening to detect the use of nonprescribed medications at any time.

8. I recognize that my chronic pain represents a complex problem that may benefit from physical therapy, psychotherapy, and behavioral medicine strategies. I also recognize that my participation in the management of my pain is extremely important. I agree to actively participate in all aspects of the Pain Management Program to maximize the likelihood that my level of functioning will increase and my ability to cope with my condition will improve.