Treatment Contract

for the use of an opioid medicine (morphine-like painkiller) for the management of chronic pain

First name *

Surname *

Date of Birth *

Please read the following document carefully to ensure you fully understand the contents. Check each box to acknowledge that you have reviewed and comprehend all statements.

My medical practitioner and I agree to the following conditions regarding my treatment and the prescribing of an opioid medicine for my pain:

1. My medical practitioner is responsible for prescribing a safe and effective dose of an opioid medicine. I will not use an opioid medicine other than at the dose prescribed and I will discuss any changes in my dose with my medical practitioner. *

2. I am responsible for the security of my opioid medicine. Lost, misplaced or stolen medicines or prescriptions for opioid medicines will not be replaced. *

3. I will only obtain my opioid medicine from the medical practitioner who signs this contract, or other doctors in the same practice authorised to prescribe to me. I understand that no early prescriptions will be provided. *

4. While most people do not have any serious problems with this type of medicine when used as directed, there can be side effects. My medical practitioner has explained the main ones to me, and I will tell him or her if I experience what could beside effects. *

5. I am aware that my medical practitioner is required to gain authorisation from the Department of Health for continued prescription of an opioid medicine. *

6. As possible dependence is an important consideration in the management of my pain, I have informed my medical practitioner of any present or past dependence on alcohol or drugs that I may have had, and of any illegal activity related to any drugs (including prescription medicines) that I may have been involved in. *

7. I am aware that providing my opioid medicine to other people is illegal and could be dangerous to them. *

8. My medical practitioner respects my right to participate in decisions about my pain management and will explain the risks, benefits and side effects of any treatment. *

9. My medical practitioner and I will work together to improve my level of functioning and reduce my pain. *

10. I understand that my medical practitioner may stop prescribing my opioid medicine or change the treatment plan if my level of activity has not improved, if I do not show a significant reduction in my pain, or if I fail to comply with any of the conditions listed above. *

I understand that an opioid medicine is to be prescribed to me in an attempt to improve my level of functioning and reduce my pain. My medical practitioner and I have discussed that strong opioid (morphine-like) medicines may only be partially helpful in achieving this goal and on occasion will not help at all. I understand that an opioid medicine is only one part of the management of my chronic pain.

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Patient Signature *

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Doctor Signature *

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Date *

Name of Doctor *