This agreement was completed and agreed to by an unnamed user at XX:XXpm on XX/XX/XXXX via scriptulate.com/opioid-agreement
Opioid Agreement
Patient Name:
Date Signed:
The below agreement provides you with a high level overview of your expectations as a patient using opioids.
The goal of this agreement is to keep you informed about the risks of your treatment and to note any questions you may have.
Sections fully understood and agreed to by the patient are marked 'Agreed.' Any section not agreed to is marked with the patient's comments.
Opioids are dangerous medications that can cause serious harm.
Common side-effects include constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence, and withdrawal symptoms when stopping opioids.
The potential risk of opioid use disorder (addiction) increases significantly with long-term use.
Opioids increase your risk of potentially fatal respiratory depression. The risk is multiplied when opioids are combined with alcohol or benzodiazepines (e.g., Ativan, Xanax).
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Your providers can only treat you effectively if they fully understand the drugs you are taking. This includes prescription drugs, over-the-counter drugs, supplements, and herbal medications as any combination of these could be counterproductive or dangerous. Do you agree to...
- Follow your provider's dosage instructions?
- Not alter your dose?
- Not alter your frequency?
- Notify your provider of new medications/prescriptions before you begin taking them?
Agreed
Although opioids can reduce pain when other measures fail, there is no sufficient evidence that opioids alone improve pain or function with long-term use. Complementary approaches have been proven to improve function—with or without limited opioid use—including:
- Meditation
- Physical therapy
- NSAIDs (only if directed)
- At-home exercise
Do you agree to work with your providers to minimize opioid use and participate in physical therapy, prescribed home exercise, and other approaches as directed?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Opioid overdose can happen even when you are taking your medications as directed. This leads to troubled breathing, especially when combined with alcohol and benzodiazepines, which can lead to death.
Naloxone (e.g., Narcan) temporarily reverses respiratory depression (for about 30 minutes) prior to obtaining emergency medical care.
Do you agree to learn how to use naloxone, train someone in your house how to use naloxone, and carry naloxone all the time?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
The risks of illicit drugs like heroin, cocaine, marijuana, amphetamines, or fentanyl can be compounded by opioids.
Taking drugs prescribed for someone else or purchasing them illegally can significantly increase your risk of injury and death.
Do you agree not to use illicit drugs or drugs not prescribed to you?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Opioids are the largest cause of accidental death in America. Providers are responsible for checking for potential abuse and signs of addiction and may use various examination techniques, questionnaires, and testing available to identify potential abuse, diversion (selling pills), and non-adherence.
Use of the tools is often mandated by regulators or health systems and does not mean that your provider suspects abuse or diversion.The following tools may be utilized randomly and without much warning...
Your providers can check a state database of
all controlled substances that you have been prescribed in the past two years—including opioids. This is usually a required step, and it is important to prevent dangerous drug interactions and to check for doctor shopping.
Do you understand that your provider can monitor all controlled substance prescriptions?
Do you agree that if you receive a controlled substance prescription from another provider, you will notify all of your providers immediately?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Random drug toxicity screens confirm adherence to your provider’s instructions and check for abuse and diversion.
Do you agree to submit to regular and/or random drug toxicity screens at any point during your treatment?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Pill counts help to rule about diversion and abuse and keep your provider compliant. You may be asked to count all unused pills—or bring in your pill bottle—within 24 hours of being notified by the provider’s office.
Do you agree to keep your contact information up to date, and understand that a changed or disconnected phone number will count as a no show and violation of this agreement?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Pill counts help to rule about diversion and abuse and keep your provider compliant. You may be asked to count all unused pills—or bring in your pill bottle—within 24 hours of being notified by the provider’s office.
Do you agree to keep your contact information up to date, and understand that a changed or disconnected phone number will count as a no show and violation of this agreement?
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Leftover opioids, benzodiazepines and stimulants are frequently the root cause of addiction amongst family members, friends, and anyone else with access to your medicine cabinet.
Do you agree to:
- keep your prescriptions safe and secure from other family members and friends?
- Properly dispose of unused medication within 15 days of discontinuation?
Note: your providers may NOT provide additional medication if your prescription is lost or stolen
Agreed
Marked unsure with the following comment:
Section explained and agreed to on (date) by (provider initials) and (patient initials)
Adherence to this agreement will optimize the outcome of your treatment. This agreement exists to protect both you and your providers.
The patient named below agrees to adhere to the sections that they just read through. They also agree that violating this agreement may be considered a violation of trust between them and their provider(s), which may force their provider to cease opioid treatment altogether.
Provider Name: Signature: Date:
Patient Name: Signature: Date: