PLEASE REVIEW ALL CONDITIONS BEFORE SIGNING
I, _______________________________________ , understand that I am being prescribed an opioid medicine in an attempt to
reduce my pain and improve my level of functioning. My medical practitioner (doctor) and I have discussed that opioids can help
contribute to achieving these goals for some patients, however, for others they may not be helpful at all. I understand that an
opioid medicine is only one component of my plan for managing chronic pain.
My doctor and I have discussed and jointly agree to the following conditions:
1.
My doctor is responsible for prescribing a safe and eective dose of an opioid medicine. I will not use an opioid other than
at the dose prescribed and I will discuss any changes in my dose with my doctor.
2.
I will only obtain my opioid medicine using a prescription from the doctor who signs this contract, or from other doctors in
the same practice authorised to prescribe to me. I understand that no early prescriptions will be provided.
3.
I am responsible for the security of my opioid medicine. I acknowledge that lost, misplaced or stolen medicines or
prescriptions for opioids will not be replaced.
4.
While most people do not have serious problems with this type of medicine when used as directed, there can be some
adverse eects. My doctor has explained to me the main potential adverse eects and I will inform them if I experience
any unexpected problems or concerning eects.
5.
I acknowledge that possible dependence is an important consideration when deciding if an opioid medicine should be
used for pain management, and I have informed my doctor of any present/past:
Dependence on alcohol or drugs
Illegal activity related to any drugs (including prescription medicines)
6.
I am aware that providing my opioid medicine to other people is illegal and could endanger them
7. I am personally responsible for making sure I am t to drive or operate heavy machinery while taking an opioid. I will not
do these activities at times when the opioid dose is being increased or if I feel cognitively impaired.
8.
My doctor respects my right to participate in decisions about my own pain management and will explain the risks, benets
and adverse eects of any treatment
9.
My doctor and I will work together to reduce my pain and improve my level of functioning
10. I understand and accept that my doctor may stop prescribing my opioid medicine or change the treatment plan if my
level of activity has not improved, if I do not show a signicant reduction in my pain, or if I fail to comply with any of the
conditions listed above
Patient’s signature: __________________________________________ Date: _________________________________________
Medical practitioner’s signature: _______________________________ Date: _________________________________________
PLEASE PROVIDE A COPY OF THE SIGNED CONTRACT TO THE PATIENT
Adapted from: Prescribing drugs of dependence in general practice, Part C1. Opioids. Appendix B2. Drugs of
dependence treatment agreement/contract. The Royal Australian College of General Practitioners. 2017. Available
at: www.racgp.org.au/download/Documents/Guidelines/Opioid/addictive-drugs-guide-c1.pdf (Accessed Dec,
2022)
Treatment contract for opioid use in the management of chronic pain
Patient’s name: Date of birth:
Address:
Medical practitioner’s name:
