Your Pain Treatment Agreement

Medically Reviewed by Tyler Wheeler, MD on March 13, 2024
Written by WebMD Editorial Contributors
3 min read

Managing chronic pain with opioids is complicated and challenging. Doctors need to know if patients can follow the treatment plan, if they get desired responses from the meds, and if there are signs of developing addiction. And, patients need to know the potential risks of opioids, as well as the expectations to minimize those risks. Physicians use "medication contracts" to make sure that the patient and provider are on the same page before starting opioid therapy. Such agreements are most commonly used when narcotic pain relievers are prescribed.

The use of a pain management agreement allows for the documentation of understanding between a doctor and patient. Such documentation, when used as a means of facilitating care, can improve communication between doctors and patients.

If your doctor asks you to sign a pain treatment agreement, discuss any concerns you may have with the doctor before signing the agreement. Questions you may want to ask include:

  • What medications does the agreement include?
  • What risks are involved with my taking these medications?
  • How does the agreement affect emergency care?
  • What if I fail to follow the agreement?

A pain management agreement may include statements such as those listed in the sample document below.

I understand that I have a right to comprehensive pain management. I wish to enter a treatment agreement to prevent possible chemical addiction. I understand that failure to follow any of these agreed statements might result in Dr. __________________________ not providing ongoing care for me.

I, _________________________________________________, agree to undergo pain management by Dr. _____________________________. My diagnosis is __________________________________________________________________. I agree to the following statements:

I will not accept any narcotic prescriptions from another doctor.
I will be responsible for making sure that I do not run out of my medications on weekends and holidays, because abrupt discontinuation of these medications can cause severe withdrawal syndrome.
I understand that I must keep my medications in a safe place.
I understand that Dr. _______________________________ will not supply additional refills for the prescriptions of medications that I may lose.
If my medications are stolen, Dr. _______________________________ will refill the prescription one time only if a copy of the police report of the theft is submitted to the physician's office.
I will not give my prescriptions to anyone else.
I will only use one pharmacy.
I will keep my scheduled appointments with Dr. ________________________ unless I give notice of cancellation 24 hours in advance.
I agree to refrain from all mind/mood altering/illicit/addicting drugs including alcohol unless authorized by Dr. ______________________.

My treatment plan may change based on outcome of therapy, especially if pain medications are ineffective. Such medications will be discontinued.
My treatment plan includes:

Medications ______________________________________________________

Physical therapy/exercise _______________________________________________

Relaxation techniques_______________________________________________

Psychological counseling _______________________

I understand that Dr. ____________________________ believes in the following "Pain Patients Bill of Rights."

You have the right to:

  • Have your pain prevented or controlled adequately.
  • Have your pain and medication history taken.
  • Have your pain questions answered.
  • Know what medication, treatment or anesthesia will be given.
  • Know the risks, benefits, and side effects of treatment.
  • Know what alternative pain treatments may be available.
  • Ask for changes in treatments if your pain persists.
  • Receive compassionate and sympathetic care.
  • Receive pain medication on a timely basis.
  • Refuse treatment without prejudice from your physician.
  • Include your family in decision-making.

A. The doctor may terminate this agreement at any time if they have cause to believe that I am not complying with the terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my compliance with the terms of this agreement.

B. I understand that I may terminate this agreement at any time.

If the agreement is terminated, I will not be a patient of Dr. _____________________ and would strongly consider treatment for chemical dependency if clinically indicated.


______________________________ ______________

Patient Signature Date

 

______________________________ ______________

Physician Signature Date

 

______________________________ ______________

Witness Signature Date