Sedative-Hypnotic Agreement Examples of Sedative-Hypnotics

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London Breed

Mayor

San Francisco Health Network Behavioral Health Services

Medication Use Improvement Committee

1380 Howard St. 5

Floor

San Francisco, CA 94103

Sedative-Hypnotic Agreement

Examples of Sedative-Hypnotics:

Lorazepam (Ativan)

Clonazepam (Klonopin)

Diazepam (Valium)

Alprazolam (Xanax)

Zolpidem (Ambien)

Zaleplon (Sonata)

Temazepam (Restoril)

Chlordiazepoxide (Librium)

Purpose:

To describe what I can expect from my provider and what my provider expects of me in order to

be more safely prescribed a sedative-hypnotic.

Potential risks:

These medications carry serious risks that include, but are not limited to:

 Potentially lethal interaction with alcohol and drugs

 Sedation

 Loss or decrease of behavioral control

 Worsening depression

 Worsening memory and/or difficulty thinking clearly

 Worsening of a sleep disorder, especially sleep apnea

 Rebound anxiety and panic attacks

 Falls

 Serious withdrawal that can include seizures and death

 Addiction

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My responsibilities:

 I agree to come to my regularly scheduled appointments

 I understand that if I run out of medications early for any reason, these may not be refilled

early.

(Examples: lost medications, stolen medications, taking more than prescribed)

 I agree to store my medications in a safe place, away from children.

 I agree to receive sedative-hypnotic medications only from this clinic.

 I will notify my provider immediately if I am prescribed any new medications or develop

any new medical conditions. I understand that my prescriber has access to all pharmacy

records and this may be regularly reviewed.

 I understand that I may be required to do a drug test at any time.

 I agree to allow all of my providers to communicate with each other including my

methadone provider (if applicable).

My provider’s responsibilities:

 Assess my symptoms

 Create/monitor an appropriate treatment plan that is as safe as possible

 Give clear instructions on taking this medication

 Stop the medication if at some point the risks outweigh the benefits

 Offer additional clinician support, such as counseling or education, for treatment of my

anxiety and/or sleep issues, as applicable

Medication Instructions:

You are prescribed the following: ________________________________________

This medication is intended for short-term use only

Take this medication as directed

Avoid alcohol and narcotics (for example, Norco, Vicodin, Percocet, Morphine) while using this

medication to avoid potentially life-threatening interactions.

I understand that if I do not follow this agreement, this medication may be stopped.

Patient: _______________________________ Date:______________________

Provider: ______________________________ Date:______________________