I understand that Dr ____________ is prescribing opioid medication to assist me in managing chronic pain that has not responded to other treatments. The risks, side effects, and benefits have been explained to me, and I agree to the following conditions of opioid treatment. Failure to adhere to these conditions will result in discontinuing the medication.

1. The medication must be safe and effective. The goal is to use the lowest dose that is both safe and effective.
2. The medication must assist me to function better. If my activity level or general function gets worse, the medication will be changed or discontinued.
3. I will participate in other treatments that Dr ____________ recommends and will be ready to taper or discontinue the opioid medication as other effective treatments become available.
4. I will take my medications exactly as prescribed and will not change the medication dosage or schedule without Dr ____________’s approval.
5. I will keep regular appointments at the pain clinic.
6. One doctor. All opioid and other controlled drugs for pain must be prescribed only by Dr __________.
7. If I have another condition that requires the prescription of a controlled drug (narcotics, tranquilizers, barbiturates, or stimulants) or if I am hospitalized for any reason, I will inform the pain clinic within one business day.
8. I will designate one pharmacy where all my prescriptions will be filled.
9. I understand that lost or stolen prescriptions will not be replaced, and I will not request early refills.
10. I agree to abstain from all illegal and recreational drugs and will provide urine or blood specimens at the doctor’s request to monitor my compliance.

    Signature: ___________________________________

    Date: _______________________________________
    (Patient)

    Signature: ___________________________________

    Date: _______________________________________
    (Chronic Pain Management staff)