"Sample Patient Contract for Using Opioid Pain Medication in Chronic Pam"

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Sample Patient Contract
for
Using Opioid Pain Medication in Chronic Pam
This is an agreement between ___________________________________ (the patient) and
Dr._________________________________ (the doctor) concerning the Use opioid analgesics
(narcotic pain-killers) for the treatment of chronic pain problem. The medication will probably
not completely eliminate my pain, but is expected to reduce it enough that I may become more
functional and improve my quality of life.
1.
I understand that opioid analgesics are strong medications for pain relief and I. have been
informed of the risks and side effects involved with taking them.
2.
In particular, I understand that opioid analgesics could cause physical dependence. If I
suddenly stop or decrease the medication, I could have withdrawal symptoms (flu-like syndrome
such as nausea, vomiting diarrhea, aches, sweating, chills) that may occur within 24-48 hours of
the last dose. I understand that opioid withdrawal is quite uncomfortable but not a life-
threatening condition.
I understand that if I am pregnant or become pregnant while taking these opioid
medications, my child would be physically dependent on the opioids, and withdrawal can be life-
threatening for a baby.
3.
Overdose on this medication may cause death by stopping my breathing; this can be
reversed by emergency medical personnel if they know I have taken narcotic pain-killers. It is
suggested that I wear a medical alert bracelet or necklace that contains this information.
4.
If the medication causes drowsiness, sedation, or dizziness, I understand that I must not
drive a motor vehicle or operate machinery that could put my life or someone else’s life in
jeopardy.
5.
I understand it is my responsibility to inform the doctor of any and all side effects I have
from this medication.
6.
I agree to take this medication as prescribed, and not to change the amount or frequency
of the medication without discussing it with the prescribing doctor. Running out early, needing
early refills, escalating doses without permission, and losing prescriptions may be signs of
misuse of the medication, and may be reasons for the doctor to discontinue prescribing to me.
7.
I agree that the opioids will be prescribed by only one doctor, and I agree to fill my
prescriptions at only one pharmacy. I agree not to take any pain medication or mind altering
medication prescribed by any other physician without first discussing it with the above named
doctor. I give permission for the doctor to verify that I am not seeing other doctors for opioid
medication or going to other pharmacies.
8.
I agree to keep my medication in a safe and secure place. Lost, stolen, or damaged
5
Sample Patient Contract
for
Using Opioid Pain Medication in Chronic Pam
This is an agreement between ___________________________________ (the patient) and
Dr._________________________________ (the doctor) concerning the Use opioid analgesics
(narcotic pain-killers) for the treatment of chronic pain problem. The medication will probably
not completely eliminate my pain, but is expected to reduce it enough that I may become more
functional and improve my quality of life.
1.
I understand that opioid analgesics are strong medications for pain relief and I. have been
informed of the risks and side effects involved with taking them.
2.
In particular, I understand that opioid analgesics could cause physical dependence. If I
suddenly stop or decrease the medication, I could have withdrawal symptoms (flu-like syndrome
such as nausea, vomiting diarrhea, aches, sweating, chills) that may occur within 24-48 hours of
the last dose. I understand that opioid withdrawal is quite uncomfortable but not a life-
threatening condition.
I understand that if I am pregnant or become pregnant while taking these opioid
medications, my child would be physically dependent on the opioids, and withdrawal can be life-
threatening for a baby.
3.
Overdose on this medication may cause death by stopping my breathing; this can be
reversed by emergency medical personnel if they know I have taken narcotic pain-killers. It is
suggested that I wear a medical alert bracelet or necklace that contains this information.
4.
If the medication causes drowsiness, sedation, or dizziness, I understand that I must not
drive a motor vehicle or operate machinery that could put my life or someone else’s life in
jeopardy.
5.
I understand it is my responsibility to inform the doctor of any and all side effects I have
from this medication.
6.
I agree to take this medication as prescribed, and not to change the amount or frequency
of the medication without discussing it with the prescribing doctor. Running out early, needing
early refills, escalating doses without permission, and losing prescriptions may be signs of
misuse of the medication, and may be reasons for the doctor to discontinue prescribing to me.
7.
I agree that the opioids will be prescribed by only one doctor, and I agree to fill my
prescriptions at only one pharmacy. I agree not to take any pain medication or mind altering
medication prescribed by any other physician without first discussing it with the above named
doctor. I give permission for the doctor to verify that I am not seeing other doctors for opioid
medication or going to other pharmacies.
8.
I agree to keep my medication in a safe and secure place. Lost, stolen, or damaged
5
medication will not be replaced.
9.
I agree not to sell, lend, or in any way give my medication to any other person.
10.
I agree not to drink alcohol or take mood altering drugs while I am taking opioid
analgesic medication. I agree to submit a urine specimen at any time that my doctor requests,
and give my permission for it to be tested for alcohol and drugs.
11.
I agree that I will attend all required follow-up visits with the doctor to monitor this
medication, and I understand that failure to do so will result in discontinuation of this treatment.
I also agree to participate in other chronic pain treatment modalities recommended by my doctor.
12.
I understand that there is a small risk that opioid addiction could occur. This means that I
might become psychologically dependent on the medication, using it to change my mood or get
high, or be unable to control my use of it. People with past history of alcohol or drug abuse
problems are more susceptible to addiction. If this occurs, the medication will be discontinued
and I will be referred to a drug treatment program for help with this problem.
I have read the above, asked questions, and understand the agreement. If I violate the agreement,
I know that the doctor may discontinue this form of treatment.
______________________________________________________________________________
Patient signature
_____________________________________________________________________________
Doctor signature
__________________________________
Date
Addendum:
Sample Statement that could be in this agreement or included in chart at each visit:
I understand that the medication is prescribed as follows:
Type of medication _________________________________________________
Number of pills and frequency ________________________________________
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Total number of pills ________________________________________________
Next refill due _____________________________________________________
_________________________________________________________________
Patient signature
__________________________________________________________________
Doctor signature
This could avoid confusion if you are out of the office. If the patient is calling in for early refill,
or if the patient says that you told them something different
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