Indication
Pain - plan agreement
RAG rating
n/a
Document type
Patient information
Place
Hertfordshire and West Essex ICB
Output type
Pharmacy / Prescribing
Document
Download

Opioid

Opioid Management Plan: Treatment Agreement

Patient Name: ……………………………….……………………………….

NHS number: ………………………………………………………………….

Condition(s) being managed with opioids:

New opioids being prescribed when this agreement starts:

(This is for a trial period during which the prescriber will need good evidence of improvement in function before embarking on long term treatment)

Period before next mandatory review:

(For new trials 2-4 weeks, for long-term prescription 6–12 months)

Patient Declaration

  1. In signing this agreement, the patient agrees to the following conditions regarding their treatment and the prescribing of an opioid medication [Delete points as necessary]:
  2. I have read the ‘Thinking About Opioid Treatment For Pain’, Driving-and-Pain-patient-information’ and ‘Taking Opioids For Pain’ information leaflets and I will tell my GP practice team if I experience any on-going/intolerable side effects.
  3. I agree to follow a medicine free alternative pain management pathway as signposted by my GP practice team, if I am asked to do so.
  4. I agree that my GP practice team is responsible for prescribing a safe and effective dose of the opioid medication. They will control my dose, with advice from one or more hospital specialists in a condition relevant to my pain if necessary.
  5. I will follow the directions given to me by my GP practice team; I will not increase my dose and will discuss any changes in my dose with them.
  6. I will only use opioids prescribed by my GP practice team.
  7. I will only obtain my opioid medication with prescriptions from my GP practice team.
  8. I understand that prescriptions will not be provided before they are due according to your agreed treatment schedule.
  9. I will report any side effects/withdrawal symptoms to my GP practice team.
  10. I understand that any evidence of unsafe use may result in closer monitoring and increased frequency of prescription collection with reduced amounts of opioids. Examples of this are:
  • drug hoarding,
  • acquisition of any opioid medication or other pain medication from other sources,
  • uncontrolled dose escalation,
  • continual loss of prescriptions,
  • failure to follow the agreement.

I am responsible for the security of my opioid medication at home. I understand that lost, misplaced or stolen medication or prescriptions for opioid medicines may not be replaced. In the event that opioid medication is stolen, I will report this to the police.

I am aware that giving my opioid medication to other people is illegal and could be dangerous to them.

Patient’s Signature: ……………………………………….……………………………………………Date: ……………………………

Clinician’s Signature: ……………………………………………………………………………………Date: ……………………………

Version number
1.0
Developed by
HWE ICB PMOT
Approved by
HWE APC
Date approved / updated
July 2022
Review date
This HWE APC document is based upon the information available at the time of publication. This document will be reviewed upon request in light of new information becoming available.
Superseded version
n/a
Back