THIS DOCUMENT IS MERELY AN EXAMPLE OF A PHYSICIAN/PATIENT
OPIOID CONTRACT AND IS NOT INTENDED TO BE USED AS WRITTEN
BY EVERY PHYSICIAN AND PATIENT. IF A PHYSICIAN AND PATIENT
SEEK TO ENTER INTO AN OPIOID CONTRACT, THEY SHOULD CONSULT
WITH LEGAL COUNSEL TO ENSURE THAT THE CONTRACT MEETS ALL APPLICABLE
LEGAL STANDARDS AND ADDRESSES THE PARTICULARS OF EACH PHYSICIAN/PATIENT
RELATIONSHIP AND TREATMENT PROTOCOL. RSDSA ASSUMES NO LIABILITY
IN CONNECTION WITH THE EXECUTION OF THIS OR ANY OTHER PHYSICIAN/PATIENT
Reprint from: Kirkpatrick AF, Derasari M, Kovacs PL, Lamb BD, Miller R,
A Protocol-Contract for Opioid Use
in Patients with Chronic Pain Not Due to Malignancy. J Clin
Patient’s Name: ___________________________________
OPIOID TREATMENT PROTOCOL
The use of opioids (also called narcotics) to treat patients
dying from cancer is well-established. However, the use of
opioids to treat non-cancer patients suffering from chronic
pain is controversial. The opioid you will be taking is called
__________. This opioid is designated as a controlled substance
by the U.S. Drug Enforcement Agency (which means the drug
has the potential for abuse, addiction, and illegal diversion).
The purpose of this contract is to summarize an agreement
among all parties involved in the care of the above named
patient. The ultimate responsibility for management of the
patient’s chronic pain is placed upon the patient. Our responsibility
is to help the patient to become as effective a manager of
the pain experience as possible. The patient agrees to decrease
reliance on opioid use as much as possible and to focus more
on issues of minimizing suffering, changing attitudes and
lifestyle, reducing disability, and accepting responsibility
for one’s own health destiny.
The patient will agree to the following (as indicated by the
signature to this contract):
1. The patient will visit and be re-evaluated by the prescribing
physician and the patient’s psychologist (or psychiatrist)
at least once every month during the initial trial period,
unless notified by the physician involved. After the initial
trial period, the patient will be re-evaluated at least once
every 3 months. All re-evaluations will be scheduled appointments,
not walk-in appointments.
2. There will be no change in the patient’s prescriptions
by telephone. The patient must appear in person and will not
be allowed to change the dosing without prior authorization.
One physician will assume responsibility for all pain medication,
and no other physician(s) will prescribe them.
3. The patient will keep a daily record of all opioid tablets
taken. This information will be provided to the prescribing
physician and psychologist (or psychiatrist) in a summarized
form, by the patient, at each office visit. In addition, at
each visit, the patient will provide a list of all opioids
in his or her possession to ensure that all opioids are accounted
4. The patient has agreed not to take the opioid tablets
unless the pain limits the patient’s function significantly
or if the pain is severe. It is not appropriate for the patient
to attempt total relief of the pain with opioid. To do so
places the patient at increased risk of respiratory depression,
sedation, nausea, constipation, and tolerance. A 50% reduction
in pain is a realistic goal.
5. The patient must report significant side effects due to
opioid; for example, over sedation, nausea, vomiting, constipation,
confusion, euphoria (high feelings), and dysphoria (down feelings).
There are other side effects which are very rare. These side
effects, which may be related to opioid use, include nausea,
vomiting, dizziness, sweating, respiratory depression, gastrointestinal
upset, involuntary movements, jerks or tremors, headaches,
weakness, seizures, bad dreams, muscle rigidity, transient
hallucinations and disorientation, visual disturbances, insomnia,
dry mouth, diarrhea, stomach cramps, taste alterations, flushing
of face, decreased blood pressure, difficulty with urination,
itching, skin rashes, and swelling of skin.
6. The goal in prescribing pain medications is to reduce
the need for them in a reasonable amount of time. For example,
the underlying pain may decrease over time, and the patient
should attempt to learn safer ways to manage his or her pain
(e.g., relaxation techniques, self hypnosis, biofeedback,
etc.). Approximately every 6 months, the need for this medication
will be re-evaluated and the patient agrees to attempt to
reduce or discontinue the pain medication altogether.
7. The patient understands that:
a. Patients who take opioids can potentially develop
psychological and/or physical dependence and/or tolerance.
b. Opioids may impair mental and/or physical ability
required for the performance of potentially hazardous
tasks (e.g., driving, operating a machine).
c. Opioids should not be taken with alcohol or other
CNS (central nervous system) depressants (sleep aids,
tranquilizers) because addictive effects, including CNS
depression, may occur. The physician prescribing the opioid
should be consulted if other medications are currently
being used or are prescribed for future use. Failure to
report the use of any pain medications, other than those
prescribed by this physician, shall be a breach of contract
by the patient and constitutes sufficient cause for termination
of this contract.
d. The patient understands that sometimes abrupt cessation
or a sudden reduction in a dose of opioid after prolonged
use may result in withdrawal symptoms (initial symptoms
including sweating, gooseflesh, tearing of eyes, runny
nose, yawning, restless sleep, and enlarged pupils). After
24 to 72 hours, the symptoms may include irritability,
anxiety, weakness, twitching and spasm of muscle, diarrhea,
kicking movements, severe backache, stomach (abdominal)
and leg pain and cramps, hot and cold flashes, insomnia,
nausea, loss of appetite, vomiting, increased body temperature,
increased breathing rate, blood pressure, heart rate,
and sneezing. Excessive loss of fluid from increased sweating,
diarrhea, and vomiting may lead to severe dehydration.
Death may occur. Without treatment, most symptoms from
opioid withdrawal disappear in 5 to 14 days; Some symptoms
such as inomnia, irritability and muscle aches, may last
2 to 6 months. After 72 hours of withdrawal, it is unlikely
that withdrawal symptoms will worsen.
e. Tablets must be taken whole, and are not to be broken,
chewed, or crushed. Otherwise, the opioid could be rapidly
absorbed causing toxicity.
f. If the patient fails to comply with the requirements
of this treatment protocol, the physician prescribing
the opioid may discontinue the opioid at an appropriate
rate (detoxification from opioid) and discontinue the
doctor-patient relationship with the patient. Similarly,
any unethical behavior by the patient will be grounds
to discontinue the care of the patient (e.g., diversion
or selling opioids to others or taking opioids for emotional
reasons). The patient understands that he or she already
has a chronic pain problem, and that we do not want to
add a drug problem. The patient understands that successful
treatment of the chronic pain will require more than pain
medication; it will require learning new pain management
strategies, increasing activity, and becoming as healthy
as possible. One of the treatment goals for many patients
is the eventual discontinuation of all opioids and other
pain medications where advisable.
g. If the patient becomes stabilized on an effective
dose of opioids, a primary care physician may assume the
responsibility for the patient’s care, including the writing
of prescriptions for opioids. The patient will follow
the requirements dictated by the new physician who is
prescribing the opioids.
h. The patient agrees to the use of periodic drug screens
to assure appropriate use of medications.
1. The patient will undergo a therapeutic trial with opioids
to determine if he/she is a candidate for continued use.
2. Prescription of opioid will only be renewed on a monthly
3. Confusion caused by the opioid, which cannot be controlled
by adjustments of dosage, will be a basis for discontinuing
its use and considering an alternative treatment.
4. Sedation without confusion may be treated by decreasing
the dose of opioid.
5. It may be necessary to treat nausea and vomiting with
Reglan 10 mg q6h or Compazine 10 mg q6h, by oral or rectal
6. The patient may be treated for constipation by adjustment
of diet or with:
a. Colace 200 mg b.i.d
b. Concurrent administration of Senokot, two tablets
b.i.d. This may be increased to four tablets b.i.d. In
addition, the patient may take Dulcolax suppositories,
1 PRN q daily.
7. The patient will actively pursue and document other non-medication
methods of managing pain. These other methods may include
relaxation training, self hypnosis, biofeedback, meditation,
pool exercises, and/or any other modalities that may be helpful
in reducing pain, increasing pain tolerance, or increasing
levels of life-enhancing activities.
I, (the patient), have read, understood, and agreed to abide
by the contents of this document.
Psychologist (or Psychiatrist)