Opioid Agreement

For patients using narcotics for chronic pain conditions

The goal of using narcotics for treatment of chronic pain is to improve function. It is not meant to take away all pain. Using narcotics to treat pain is just one part of my pain treatment plan. 

  • I understand that my provider and I will work to find the best treatment for my pain. I understand that I must use other pain control therapies along with the narcotics to better manage my pain. I understand that my provider and I will often discuss how well the narcotics are working for me and make changes as needed.
  • I agree to take the medicine at the dose and times that my provider prescribed. I agree not to increase the dose of narcotics on my own and understand that doing so may lead to this treatment being stopped. 
  • I agree to get narcotics only from my provider, Amit Goswami, M.D. (or a provider assigned to cover for them in their absence.) Routine follow-up care is required. Only my provider (or assigned provider in their absence) can prescribe narcotics for me at scheduled clinic visits. I agree to make a clinic visit with my provider at least every 90 days to evaluate my pain and the medicine I’m taking. I understand that my provider may want to see me more often than every 30 days and I agree to attend all appointments. If I do not visit with my provider at least every 30 days this Agreement will end and I will be slowly taken off my pain medicine. 
  • I understand that my provider may get information from any outside health care provider, pharmacist, or the New Jersey or New York State Narcotics Data Base about use or possible misuse of alcohol and other drugs. 
  • I will allow my provider to contact my family members if they are concerned about how I am using my pain medicine. I will agree to be seen at the Substance Use Disorders Clinic if I am becoming addicted to my pain medicine. 
  • I understand that my doctor will prescribe narcotics only during clinic days and not on other weekdays. No prescriptions will be written in evenings, weekends or holidays. I will bring all my pain medicine to every visit with my provider. 
  • If I feel tired or mentally foggy, I will not drive, operate heavy machines, or work in a job dealing with public safety. 
  • I agree to never take more than the amount prescribed by my provider. I agree to keep my medicines in a secure place. If my medicines are stolen, I will report this to the police and my provider. I understand that lost, stolen or destroyed narcotics will not be replaced. 
  • I understand that I cannot get a refill on my narcotics early. If I lose my medicine or take more than prescribed, I will have to wait until the next refill is due. 
  • If the narcotics are not effective in decreasing my pain, my provider may choose to take me off the narcotics and offer a different treatment to help with my pain. 
  • Under NO circumstances will I allow other people to take my pain medicine. 
  • Changes in dose or how often I take my medicine can be discussed during regular visits with my provider.
  • It is understood that health care emergencies do arise and that I may need emergency medical care at some point.
  • But, a visit to ANY emergency department for the sole purpose of getting more pain medicine will be grounds for ending this Agreement. 
  • I understand that this Agreement can end if I cancel or fail to show up for clinic visits more than 2 times in a year. In this case my provider will slowly lower my dose until I am off the narcotics. 
  • I agree to random urine or blood drug screenings, ordered by my provider, to test for narcotics and other drugs. This is used to monitor my drug use. My provider may ask a clinic staff member to watch me as I give a urine sample. If I refuse to give a random sample of urine or blood the Agreement will end. My provider will stop prescribing narcotics and will slowly take me off these medicines. 

I understand the potential side effects and risks of narcotic use which include but are not limited to: 

  1. Sleepiness, confusion
  2. Impaired mental or physical abilities
  3. Constipation
  4. Nausea, vomiting and/or decreased appetite
  5. Tolerance – needed more medicine to provide same amount of pain relief
  6. Physical dependence
  7. Physical withdrawal
  8. Overdose that can result in decreased breathing and death
  9. May increase dangerous side effects when used with other medicines or alcohol
  10. Decreased libido & erectile dysfunction

( ) Initials 

I understand that narcotics will be stopped and this Agreement ended if: 

  1. My provider feels the medicine is either harming me, not giving me good pain control, or my functional ability does not improve.
  2. I sell, abuse or misuse my medicine.
  3. I develop major side effects4. I often request increases in my dosage, or request early refills (unless for the sole purpose of controlling pain) or get narcotics from other sources.5. I am abusing illegal drugs, alcohol, and/or medicine not prescribed to me.

( ) Initials 

A copy of this Agreement will be placed in my computer record. This Agreement is valid for the time in which I receive health care through Amit Goswami, MD or for three years after I sign this. After three years a new Agreement must be signed. I understand that my provider can stop my narcotics and slowly take me off the medicine if I do not follow this entire Agreement.