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Create a new opioid agreement

The following pages will provide 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.

When you are finished, you can save or print your agreement and bring it to your provider. All of your information stays in your browser and never touches our servers
Initiate new agreement

Opioids are risky

Opioids are dangerous medications that can cause serious harm.

Common side-effects include constipation, dry mouth, nausea, vomiting, drowsiness, lowered testosterone levels, and confusion.

The potential risk of opioid use disorder (addiction) increases significantly with long-term use.

Opioids increase your risk of potentially fatal respiratory depression (overdose). The risk is multiplied when opioids are combined with alcohol or benzodiazepines (e.g., Ativan, Xanax).
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Keeping your provider informed

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 or frequency?
  • Notify your provider of new medications / prescriptions before you begin taking them?
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Chronic pain and alternate therapies

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?
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Overdose and naloxone

Opioid overdose can happen even when you are taking your medications as directed. This leads to troubled breathing, especially when combined with alcohol or benzodiazepines (e.g. Xanax), 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?
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Illicit drug use

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?
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Abuse prevention tools

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...
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Prescription Drug Monitoring Program (PDMP)

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?
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Drug toxicity screening

Random drug toxicity screens confirm adherence to your provider’s instructions and check for abuse and diversion.

They also help your provider make better clinical decisions by providing a birds-eye view of your substance use.

Do you agree to submit to regular and/or random drug toxicity screens at any point during your treatment?
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Pill counts

Pill counts help to ensure that you understand your instructions and are taking your pills as prescribed. They also help to rule about diversion and abuse, which keeps your provider compliant.

You may be asked to bring in your pills in their original bottles 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?
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Opioid Use Disorder (OUD)

One of the most significant risks of opioid use is opioid use disorder (such as addiction, increased tolerance of opioids, and abuse).

Do you agree that the provider should do periodic assessments to identify opioid use disorder?

Do you understand that if your providers identify potential addiction, they may take corrective actions such as:

- tapering or reducing your daily opioid dosage?
- referring you to an addiction center?
- stopping opioids altogether?

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Risk to family and friends

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 provider may refuse to provide additional medication if your prescription is lost or stolen
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You're done!

Adherence to this agreement will optimize the outcome of your treatment. This agreement exists to protect both you and your providers.

Click Agree and Generate PDF to print a copy of your agreement. After printing and signing it, bring a copy into your provider's office for them to sign.
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