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Medication Certification Forms

Butalbital (Fiorinal®)

    If you are taking butalbital for a legitimate medical indication, it is imperative that you maintain a current, valid prescription on file with DOPL or URAP, just as you would with any other mood-altering or controlled substance, along with a completed copy of this form , namely, the "Prescriber's Certification of Need for Butalbital Use" and the "Participant's Certification of Need for Butalbital Use."

    Please fill out and return to DOPL or URAP this form herein you certify that (a) you are taking butalbital for a specific medical condition(s), (b) you have exhausted all other accepted options for treatment, (c) you are receiving only one prescription from a specified prescriber, (d) you are filling that prescription at only one pharmacy and (e) you are taking the medication exactly as prescribed.

    Failure to submit both documents, together as printed, within 30 days of the receipt of this letter will result in your UA being reported as positive for butalbital without mitigating prescription. This means the consequences and sequelae involved with a positive UA may be imposed by your monitoring board or committee.

    You should be aware that DOPL is watching the use of butalbital by probationers and diversionees very closely. The use of this medication is considered a red flag for possible relapse to chemical use or abuse. The prescription of this medication is generally avoided in patients with a history of chemical abuse or dependency. Since it is not yet classified as a controlled substance there is currently no way of tracking prescriptions for this medication as can be done with controlled substances, thus making this manual reporting and extra documentation necessary.

Carisoprodol (Soma®)

    If you are taking carisoprodol for a legitimate medical indication, it is imperative that you maintain a current, valid prescription on file with DOPL or URAP, just as you would with any other mood-altering or controlled substance, along with a completed copy of this form , namely, the "Prescriber's Certification of Need for Carisoprodol Use" and the "Participant's Certification of Need for Carisoprodol Use."

    Please fill out and return to DOPL or URAP this form, wherein you certify that (a) you are taking carisoprodol for a specific medical condition(s), (b) you have exhausted all other accepted options for treatment, (c) you are receiving only one prescription from a specified prescriber, (d) you are filling that prescription at only one pharmacy and (e) you are taking the medication exactly as prescribed.

    Failure to submit both documents, together as printed, within 30 days of the receipt of this letter will result in your UA being reported as positive for carisoprodol without mitigating prescription. This means the consequences and sequelae involved with a positive UA may be imposed by your monitoring board or committee.

    You should be aware that DOPL is watching the use of carisoprodol by probationers and diversionees very closely. The use of this medication is considered a red flag for possible relapse to chemical use or abuse. The prescription of this medication is generally avoided in patients with a history of chemical abuse or dependency. Since it is not yet classified as a controlled substance there is currently no way of tracking prescriptions for this medication as can be done with controlled substances, thus making this manual reporting and extra documentation necessary.

Tramadol (Ultram®)

    If you are taking tramadol for a legitimate medical indication, it is imperative that you maintain a current, valid prescription on file with DOPL or URAP, just as you would with any other mood-altering or controlled substance, along with a completed copy of this form , namely, the "Prescriber's Certification of Need for Tramadol Use" and the "Participant's Certification of Need for Tramadol Use."

    Please fill out and return to DOPL or URAP this form, wherein you certify that (a) you are taking tramadol for a specific medical condition(s), (b) you have exhausted all other accepted options for treatment, (c) you are receiving only one prescription from a specified prescriber, (d) you are filling that prescription at only one pharmacy and (e) you are taking the medication exactly as prescribed.

    Failure to submit both documents, together as printed, within 30 days of the receipt of this letter will result in your UA being reported as positive for tramadol without mitigating prescription. This means the consequences and sequelae involved with a positive UA may be imposed by your monitoring board or committee.

    You should be aware that DOPL is watching the use of tramadol by probationers and diversionees very closely. The use of this medication is considered a red flag for possible relapse to chemical use or abuse. The prescription of this medication is generally contraindicated in patients with a history of chemical abuse or dependency. Since it is not yet classified as a controlled substance there is currently no way of tracking prescriptions for this medication as can be done with controlled substances, thus making this manual reporting and extra documentation necessary.

Flexeril®

    If you are taking Flexeril® for a legitimate medical indication, it is imperative that you maintain a current, valid prescription on file with DOPL or URAP, just as you would with any other mood-altering or controlled substance, along with a completed copy of this form , namely, the "Prescriber's Certification of Need for Flexeril® Use" and the "Participant's Certification of Need for Flexeril® Use."

    Please fill out and return to DOPL or URAP this form , wherein you certify that (a) you are taking Flexeril® for a specific medical condition(s), (b) you have exhausted all other accepted options for treatment, (c) you are receiving only one prescription from a specified prescriber, (d) you are filling that prescription at only one pharmacy and (e) you are taking the medication exactly as prescribed.

    Failure to submit both documents, together as printed, within 30 days of the receipt of this letter will result in your UA being reported as positive for tramadol without mitigating prescription. This means the consequences and sequelae involved with a positive UA may be imposed by your monitoring board or committee.

    You should be aware that DOPL is watching the use of Flexeril® by probationers and diversionees very closely. The use of this medication is considered a red flag for possible relapse to chemical use or abuse. The prescription of this medication is generally contraindicated in patients with a history of chemical abuse or dependency. Since it is not yet classified as a controlled substance there is currently no way of tracking prescriptions for this medication as can be done with controlled substances, thus making this manual reporting and extra documentation necessary.

 

Controlled Substance Prescriptions

    If you are taking one or more controlled substances for a legitimate medical indication(s), it is imperative that you maintain a current, valid prescription(s) on file with DOPL or URAP along with a completed copy of this , namely, the "Prescriber's Certification of Need for Controlled Substance Use" and the "Participant's Certification of Need for Controlled Substance Use."

    Please fill out and return to DOPL or URAP this , wherein you certify that (a) you are taking CS for a specific medical condition(s), (b) you have exhausted all other accepted options for treatment, (c) you are receiving prescriptions from a specified prescriber, (d) you are filling those prescriptions at only one pharmacy and (e) you are taking the medications exactly as prescribed.

    Failure to submit both documents, together as printed, within 30 days of the receipt of this letter will result in your UA being reported as positive for CS without mitigating prescription. This means the consequences and sequelae involved with a positive UA may be imposed by your monitoring board or committee.

    You should be aware that DOPL is watching the use of CS by probationers and diversionees very closely. The use of these medications is considered a red flag for possible relapse to chemical use or abuse. The prescription of these medications is generally avoided in patients with a history of chemical abuse or dependency. They may certainly be used when indicated, but it is imperative that a genuine need exist prior to obtaining such medications and that all reasonable alternatives to the use of CS have been exhausted prior to turning to their use.


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