Take the Safe Prescriber Pledge

Staten Island Performing Provider System’s Safe Prescriber Pledge is part of the initiative to address the opioid epidemic. Medical professionals who sign this pledge are adopting practices that ensure safe prescribing of potentially addictive medicines.

By filling out the form below, you are pledging to implement the 10 elements of the Safe Prescriber Pledge into your practice.

1. Prioritize non-opioid treatment options for pain
2. Utilize the Opioid Risk Tool (ORT)* to screen all patients before prescribing controlled substances
3. Use the NYS Prescription Monitoring Program (I Stop) before writing any prescription for opiates, benzodiazepines, Medication Assisted Treatment (MAT) medications
4. Follow Centers for Disease Control (CDC) guidelines for initial and chronic medication dosing*
5. Obtain patient agreement on the risks and benefits of opioids to patients who would be receivingacute and chronic opioid prescriptions*
6. Maintain an office policy and procedure* on safe and effective management of prescribingControlled Substances (CS).
7. Prescribe Narcan for all patients on chronic opiates and MAT* and:

  a. Demonstrate how to use Narcan
b. Share information about Narcan
c. Distribute Narcan educational materials

8. Offer patients on chronic opiates, benzodiazepines and MAT information on “Tamper Resistant”caps, bottles or other medication containers
9. Complete a three-hour CME course in Pain Management, Palliative Care and Addiction every 3 years*
10. Promote safe return of unused controlled medications
*Supporting documents found in Staten Island PPS Safe Prescriber Pledge Toolkit.

  • Please print your full name.