Opioid Treatment Agreement

Document modified with permission from the College of Physicians and Surgeons of Alberta

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Patient name: ________________________________________________________________________

Date: _______________________________________________________________________________

1. Doctor and patient

I, ______________________________, agree that Dr. ______________________________ will

be the only doctor who will prescribe the opioid medication_____________________________.

I will not obtain opioid medication from another doctor. If this happens, I will tell

Dr. ______________________________ as soon as possible.

2. Treatment expectations and goals

This medication is being used to decrease the severity of my chronic pain and improve my ability

to function physically, emotionally, socially and at work. At best, opioid medication may reduce

my chronic pain by about 30% but will not completely stop my chronic pain. Because of the limit

to which it will decrease my pain, the best evidence of success from this medication is how well

it improves my function. My goals for increasing my function are

_____________________________________________________________________________

_____________________________________________________________________________.

3. I understand that if the opioid treatment does not improve my pain control or my ability to

function then it will be reduced or stopped.

4. Take as prescribed

I will take the medication at the dose and frequency ordered by my doctor. I know it is

important to take this medication at regular times and not only “when needed.” I will not

increase the dose of my opioid medication on my own and am aware that doing so may lead to

this treatment being stopped. I agree to record regularly my use of these opioid medications

and how they are working.

5. Side effects

I understand that the common side effects of opioid medication include feeling sick (nausea),

vomiting, constipation, drowsiness, dry mouth, and itchiness of the skin. With extended use I am

likely to become tolerant to these side effects, except for constipation. Constipation is a very

common side effect and I may be ordered medication to help with this problem. Other side

effects which are rare include muscle jerks or shaking, muscle spasm, feeling weak, confusion,

hallucinations, feeling disoriented, chills, changes in vision, difficulty passing urine, headaches,

skin rashes, difficulty in thinking clearly, decreased sexual function, swelling of hands or feet,

sweating, and decreased immune function.

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6. Driving

There is a risk I may become drowsy when starting opioid therapy or when the dose is increased.

I agree not to drive a motor vehicle or operate dangerous machinery until I am on a stable dose

and do not experience any drowsiness.

7. Use with other medications

I also understand that I may become very drowsy if I take opioid medication at the same time

with other medications that cause drowsiness (such as sedatives or sleeping pills) or with

alcohol. I will not take any of these without talking to my doctor first.

8. Medication complications

I understand that opioids may cause long-term complications, which may include decreased

hormones such as testosterone, unexpected increase in pain sensitivity, and changes in

breathing patterns while sleeping.

9. Addiction

I am aware that there is a small but real risk that I may become addicted to the prescribed

opioids. The risk of addiction is increased with a past or present history of substance or alcohol

use disorder, and prescribed opioids are often reported as a cause for relapse in recovering

patients. A history of substance use disorder does not preclude the use of opioids but warrants

increased pharmacovigilance. I know that my doctor may order a consultation with a specialist

in addiction medicine if there is a concern about addiction.

10. Adherence

I understand that my doctor may ask me for a urine drug screen sample or a count of my pills at

any time. This is performed routinely for all patients to improve the overall safety of using

opioids. Urine drug monitoring will also look for other substance use that increases the risks

associated with using opioids. Further refills/prescriptions will be tied to completion of urine

tests. Doctors and clinics are encouraged to consider a policy of random urines for all patients

on long-term opioid treatment that are not designated palliative or cancer patients.

11. Use of other medications

I will not use non-prescription medications containing codeine, such as Tylenol ® #1 or 222®

tablets. My doctor may request me to reduce the dose of medications (such as sleeping pills)

that increase my risk of harm when used in combination with an opioid.

12. Stopping medications and withdrawal symptoms

I understand that suddenly stopping or reducing the amount of opioid that I am taking may lead

to withdrawal symptoms. Initial symptoms may include runny nose, sweating, tearing of the

eyes, restlessness and/or diarrhea. Later symptoms may include anxiety, irritability, weakness,

twitching and muscle spasms, severe backache and abdominal pain, leg pains and cramps, hot

and cold flashes, sleeplessness, nausea, vomiting, slight fever, increased heart rate and blood

pressure. These symptoms can be minimized by slowly reducing the opioid dose and should only

be done under the direction of my doctor. If I have stopped taking my opioid medication for 3

days or more for any reason, I will not resume taking it without talking to my doctor.

13. Appointment attendance

I will attend all appointments, treatments and consultations as requested by my doctor.

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14. Running out of medication

I will plan and book appointments well in advance. I understand that if my prescription runs out

early for any reason (such as if I lose the medication, take more than prescribed or miss an

appointment) I will not be prescribed extra medications. I will have to wait until my next

prescription is due.

15. Switching to a different opioid

I agree that my doctor may switch me to a different opioid medication in the future. If this

happens, I will return the remaining quantity of my opioid medication to my pharmacy for safe

disposal. I will continue to follow the terms of this agreement for my new opioid medication.

16. Safe storage and security

I agree to be responsible for the secure storage of my medication at all times. I agree not to give

or sell my prescribed opioid medication to any other person; nor will I accept any opioid

medication from anyone else. I will keep the medication in a safe and secure place out of reach

of children.

17. One pharmacy

I will fill my prescriptions at one pharmacy of my choice, which will be

__________________________________________________________________________.

18. Specialist consultation

I understand that my physician may require me to attend a consultation with a pain and/or

addiction specialist in order to continue safely prescribing psychoactive medications.

19. Consent to share information

I agree that my doctor has the authority to share prescribing information in my patient file with

other health care professionals (including community pharmacists) when medically necessary.

20. Breaking this agreement

If I break any part of this agreement, I understand my doctor has the right to stop prescribing

opioid medications for me.

This document was discussed between me and my doctor. I was given the opportunity to ask questions.

I affirm my understanding and acceptance of the terms of this agreement by signing this document.

THIS AGREEMENT MADE THE _____ DAY OF ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

________________________________________ ________________________________________

Patient name (printed) Prescriber name (printed)

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Review dates

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature

This agreement was revisited on this _____ day of ____________________, 20_____.

________________________________________ ________________________________________

Patient signature Prescriber signature