HSS Pain Management Center: Patient Agreement for Opioid Therapy
1.
I, _______________________________ agree that Dr. ____________________________ alone will prescribe opioid pain
medication to me. That is, I will obtain all of my prescriptions for opioids from Dr. _____________________. I agree that I will
fill my opioid prescriptions at one pharmacy. If an emergency situation necessitates an exception to the aforementioned
agreements, I will inform my physician immediately.
2.
I will attend all appointments, treatments and consultations as requested by my physician. I agree to consider other pain
management strategies as may be recommended by my physician.
3.
I will take my medication only at the dose and frequency prescribed by my physician. I agree not to increase the dose of opioids
without first discussing it with my physician.
4.
I will not request prescription refills earlier than the next regular renewal date, even if the medication is lost or stolen.
5.
I agree to be responsible for the secure storage of my medication at all times. I agree not to give or sell my prescribed
medication to any other person.
6.
I understand that common side effects of opioid therapy include nausea, constipation, sweating and itchiness of the skin.
Drowsiness may occur when starting opioid therapy or when increasing the dosage. I agree to refrain from driving a motor
vehicle or operating dangerous machinery until such drowsiness disappears.
7.
I understand that in order to monitor the safety of opioid prescriptions, my physician may require urine, blood, saliva, or hair
testing to monitor for both prescribed and non-prescribed substances.
8.
Using an opioid to treat pain may result in the development of a physical dependence on this medication and increased
pain. As such, I understand that my physician may require that I see an addiction medicine specialist should a concern about
addiction arise.
9.
I understand that sudden decreases or discontinuation of the medication may lead to symptoms of opioid withdrawal.
10. The use of a mood-modifying substance, such as tranquilizers, sleeping pills, alcohol or illicit drugs (e.g. cannabis, cocaine,
heroin or hallucinogens), can cause adverse effects and/or interfere with opioid therapy. Therefore, I agree not to use any of
these substances without prior approval from my physician. I understand that I should also consult with my physician or
pharmacist before taking other medications, including over-the-counter and herbal products.
11. I consent to open communication between my physician and any other health care professionals involved in my care, including
pharmacists, other specialists, emergency medical personnel, etc.
12. I understand that if I break this agreement, my physician reserves the right to stop prescribing opioid medication to me and
may ultimately terminate our physician-patient relationship.
___________________________
Patient Name
____________________________
Signature
_______________
Date
____________________________
Relationship to Patient
_______________
Date
If signed on behalf of patient
___________________________
Signature of Parent/Guardian