Substance Use Disorders
Appendix H
Example of a Relapse Prevention Agreement
The following after-care contract is between
______________________________ (Employee)
______________________________ (Employer Representative)
Dr. ___________________________ (Primary Care Physician)
Dr. ___________________________ (Substance Use Disorder Treatment Provider) and
______________________________ (SAP [Substance Abuse Professional])
Recognizing addiction (the diagnosis of substance dependence) is a chronic illness with a significant risk of relapse, this agreement is designed to both to meet the requirements of work place safety and to maximize the chances of recovery. This agreement may also apply to the diagnosis of substance abuse.
The duration of this contract shall be for a minimum of two years, and will be subject to review. The contract may not necessarily conclude at that time.
1. Attending a minimum of three 12-step (or reasonable alternative) meetings is required on a weekly basis, (for example, NA or AA).
2. Regular visits with your primary care physician are required and the frequency of such visits to be determined between you and your physician.
3. Regular involvement with alcohol and drug counselling is required and the frequency to be determined by the Substance Use Disorder Treatment Provider.
4. Routine visits with the Substance Use Disorder Treatment Provider are required. The frequency of these visits may be adjusted according to the professional judgment of the Substance Use Disorder Treatment Provider. The patient agrees that the Substance Use Disorder Treatment Provider may be required to provide regular and routine reporting to the employer representative regarding his/her adherence.
5. You will report any absences from work to your Substance Use Disorder Treatment Provider within 24 hours to avoid a potential situation of unexplained absenteeism.
6. You will report any legal interactions or disorderly conduct that are related to alcohol or drug use (e.g., arrests, impaired driving charges, etc.) within 24 hours to the Substance Use Disorder Treatment Provider.
7. Urine drug screens, alcohol breath sampling, hair analysis, or any other method for drug use monitoring will be done on a routine and random basis. When requested to provide a random sample, the patient has 4 hours to comply with this request. Failure to comply is equivalent to a refusal and has the same consequences as a positive test.
8. You will remain abstinent from alcohol and abused substances. No prescription medication shall be taken without the prior authorization of the Substance Use Disorder Treatment Provider. No non-prescription preparations shall be taken without the prior authorization of the Substance Use Disorder Treatment Provider. The exceptions to this rule include:
- Plain aspirin
- Plain acetaminophen
- Plain ibuprofen and other over-the-counter non-steroidal anti-inflammatory drugs (NSAIDS)
9. The patient understands failure to adhere to this contract in a substantial way will result in immediate notification of the employer’s representative.
Signed at __________________ This ____________ day of ___________
Employee Signature __________________________________________
Employer Representative _______________________________________
Substance Use Disorder Treatment Provider _________________________
Primary Care Physician _______________________________________