McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Appendix B-5: Sample Opioid Medication Treatment Agreement

I understand that I am receiving opioid medication from Dr.                                        to treat my pain condition.  I agree to the following:

  1. I will not seek opioid medications from another physician.  Only Dr.                                will prescribe opioids for me.
  2. I will not take opioid medications in larger amounts or more frequently than is prescribed by Dr.                        .
  3. I will not give or sell my medication to anyone else, including family members; nor will I accept any opioid medication from anyone else.
  4. I will not use over-the-counter opioid medications such as 222’s and Tylenol® No. 1.
  5. I understand that if my prescription runs out early for any reason (for example, if I lose the medication, or take more than prescribed), Dr.                                      will not prescribe extra medications for me; I will have to wait until the next prescription is due.
  6. I will fill my prescriptions at one pharmacy of my choice; pharmacy name: ______________________________________________________________
  7. I will store my medication in a secured location.

I understand that if I break these conditions, Dr.                              may choose to cease writing opioid prescriptions for me.

— Source: Modified from Kahan 2006