Administrative — Opioid Treatment Agreement (Pain Contract)

CONTROLLED SUBSTANCE / OPIOID TREATMENT AGREEMENT

The purpose of this agreement is to create a safe plan for using controlled medications to manage pain.

Patient Name: [Patient Name] Provider: [Provider Name] I AGREE TO THE FOLLOWING RULES: 1. Single Prescriber:

I will receive opioid/controlled medications only from the provider listed above (or their covering partner). I will not seek these medications from other doctors, dentists, or ERs without notifying my primary pain provider.

2. Single Pharmacy:

I will use only one pharmacy for filling these prescriptions.

Pharmacy Name: [Pharmacy Name] Phone: [Pharmacy Phone] 3. Taking Medication:

I will take my medication exactly as prescribed. I will not take more than the dose written on the bottle. I will not chew, crush, or inject oral medications.

4. Safeguarding:

I am responsible for my medication. I will keep it in a safe, locked place. I understand that lost or stolen prescriptions will NOT be replaced early.

5. Monitoring:

* Urine Drug Screens: I agree to provide a urine sample for drug testing at any requested time.
* Pill Counts: I agree to bring my medication bottles for a pill count if requested, within 24 hours.

6. Alcohol/Illicit Drugs:

I will NOT use illegal drugs (cocaine, heroin, etc.) or excessive alcohol while taking these medications. Doing so is dangerous and may cause death.

7. Termination:

I understand that if I violate any part of this agreement, my provider may stop prescribing controlled substances and may discharge me from the practice.

Signature: __________________________ Date: [Date]

[Patient Name]

Provider: __________________________ Date: [Date]