FACILITY
SAMPLE Statement of Risks, Benefits, Alternatives, Expectations and Agreements
for the Use of Opioids for Chronic Pain
I will be receiving opioid (narcotic) medications for diagnosis of ______________________. This
decision was made because my condition is serious and other medications have not been effective at
improving my pain.
I am aware that these medications have risks including but not limited to sleepiness or drowsiness,
problems sleeping, confusion, constipation, nausea, itching, vomiting, dizziness, tolerance (needing
more drug for the same effect), dependence (not being able to stop the medication suddenly without
going into withdrawal), addiction and the fact that even with these medications, I may not have pain
relief.
Goals of Therapy for me are to be able to get into my chair and go outside the facility, participate in
activities and visit with my friends and family.
My physician is prescribing opioid therapy for my chronic pain as an attempt to increase my quality
of life and functional status.
My doctor has explained to me about chronic pain, the use of opioid therapy, and alternatives.
I understand that opioid therapy may not completely treat my pain, but that the goal is to be more
functional, not to have complete relief. I understand that opioid therapy can result in hyperalgesia or
worsened pain.
I agree to take all medications as prescribed unless I have notified my caregivers otherwise.
I can refuse doses.
I agree not to be involved in an activity that puts myself or others in danger such as operating a
motorized wheelchair or leaving the facility when drowsy.
I agree to report my pain accurately.
I agree never to share my medication with others at any time.
I agree not to hoard my medication. I agree to swallow all medication given to me and never save it
for “later.”
I agree not to take any illegal drugs or any medications not prescribed to me by my Edgemoor
physician. I understand that use of medications not prescribed may result in serious consequences
including death and that non-disclosure may result in a taper of my opioid prescriptions.
I agree to urine or blood toxicology screens at any time to monitor levels or if there is a suspicion of
drug use.
I agree to try non-opioid medications in combination with opioids and with non-pharmacological
methods to treat my pain as well as drugs.
I understand that the opioid therapy will only be continued as long as there is evidence that my
quality of life and/or functional status is being improved through the use of these medications and the
benefits outweigh the risks.
I understand the physician may change drug doses and types from time to time in an attempt to find
the best combination for me and that these changes may result in increases and decreases in pain.
I may not be able to take my medications with me when I go on pass/therapeutic leave: a substitute
may be provided, or I may have to return to the facility to receive a dose.
I UNDERSTAND AND AGREE TO THE STATEMENTS ABOVE:
Patient
Physician
Signature ________________ Date ____
Signature ________________ Date ____
Month Year
Page 1 of 1