TITLE: Guidelines for Treatment of Chronic Pain EFFECTIVE DATE: LAST REVISED DATE: LAST REVIEWED DATE:

Transcription

1 TITLE: Guidelines for Treatment of Chronic Pain EFFECTIVE DATE: LAST REVISED DATE: LAST REVIEWED DATE: Table of Contents 1. How do I conduct my first few visits with a patient who has chronic, non-cancer pain, and who may desire opioid medications? Pages If a decision is made to start opioid medications, what should I check on before writing the first Rx?... Pages Which opiates should we prescribe in the PCC, and what is the ceiling dose? Page 6 4. Should I prescribe long-acting or short-acting opioids?...page 6 5. Which opiates should I AVOID prescribing in the PCC? Page How should I follow-up with patients, after opiates have been initiated? Pages When should I escalate doses of opiates, and what is the ceiling dose? Page What should I do if I inherit a patient on chronic opiate therapy? Page When should I taper a patient off opioids? Pages How do I taper a patient off opioids? Pages If a patient has had opioids discontinued in the past, when and how should the PCP re-institute chronic opiate therapy? Page Under what circumstances can we give opioid medications for chronic pain during a walk-in visit in the PCC? Page Under what circumstances can we give benzodiazepines in the PCC? Page If a patient is on a opioid that we do not provide in the PCC, how do I convert it to hydrocodone or morphine? Page Who is on the Chronic Pain Task Force? Page How do I approach the patient with a persistently negative UDS?...Page What do I need to know about the UDS? Page Appendix A: Patient-Provider Chronic Pain Management Agreement Pages

2 1. How do I conduct my first visit with a patient who has chronic, non-cancer pain, and who may desire opioid medications? Initiation of opioid pain medications should NOT occur the first time you meet the patient. Use 2-3 successive visits (consider a one-hour visit) to get to know your patient, spending the time to o Develop a trusting relationship o Explore other options for treating chronic pain o Conduct an expanded screen for depressive disorder IF having suicidal ideations or if otherwise severely depressed, then seek immediate MH help Give the option of calling the Georgia Crisis Hotline for mental health emergencies, but also to get linked into routine mental health care: Refer to Dr. Tamara Haynes (board certified in BOTH Internal Medicine and Psychiatry) by sending her an EPIC message with MRN of patient Goal is to control depression BEFORE beginning opioid pain medications Document the pain history, including the impact of pain on the patient s functioning Explain to patient that we may never be able to make their pain go completely away, but we can help them become more functional: o Set specific goals for improving functioning RATHER than improving pain (e.g. I want to be able to walk two blocks to the bus stop. ) Perform and document a directed physical examination targeted to evaluation of the painful areas Review previous diagnostic studies/ interventions Trial of a comprehensive non-opioid medication regimen that includes the following medications BEFORE prescribing opioid medications: Acetaminophen - scheduled daily up to 2grams (or as deemed safe according to patient s chronic conditions) NSAID at anti-inflammatory doses, to be taken with food Also with daily PPI IF at high risk for GI toxicity Avoid in clinically significant renal dysfunction or systolic heart failure TCA low dose (e.g. 25 to 50 mg of Nortriptyline which is slightly less anti-cholinergic than Amitriptyline) AND assuming the patient is not suicidal 2

3 NOTE: explain to patient that the TCA is in the anti-depressant class of medications, HOWEVER it is not being prescribed at anti-depressant dosages, but at smaller dosages proven to help with chronic pain Review the side-effects of TCAs (e.g. drowsiness, dry mouth) Explain that full effect will only be seen IF the patient takes the medication regularly for at least 6-8 weeks Emphasize to patient importance of their active involvement in PT/OT: o PT/OT is more effective than any medication to reach goals o Opioids should NOT be prescribed if PT/OT is not aggressively pursued o Note: PT will dismiss patients from their clinic if several appointments are missed o Activate patient to learn stretches and exercises to be done TID every day on their own Refer to other clinics for pain management, where appropriate: o Steroid injections refer to injection clinic for small joints, refer to pain clinic for back or hip injections o Nerve blocks refer to pain clinic o Counsel patients that opioid medications are NOT prescribed in either of these clinics 3

4 2. If a decision is made to start opioid medications, what should I check on before writing the first Rx? Perform a risk-benefit assessment before initiating any opioid medications. ONLY initiate opioid medications for patients at LOW RISK for opioid abuse. Risk Level Patient Characteristics Low Risk Moderate Risk No history of substance use problem, past or current No contributory family history of substance abuse No major or untreated mental health problems History of substance use problem (treated) Family history of substance abuse Comorbid minor or past major mental health problem High Risk Current substance use problem Active addiction Major untreated mental health problem Educate patients on inability of opioids to cure chronic pain, though they may help improve function Encourage patient to set SPECIFC goals to address function (e.g. I want to walk two blocks to grocery store); assess improvement in function at each subsequent visit Complete an electronic (or written) pain contract, and document in note (see Appendix A) Perform a baseline UDS screening at time of initiation (do NOT initiate opioids if UDS positive for opioids, cocaine, benzodiazepines, amphetamines) Check the GA prescription drug registry ( to ensure patient has not filled any other opioid medications or benzodiazepines (if so, they cannot receive opioids from you). Do NOT initiate and/ or taper off opioids if: o Multiple opioid prescriptions have been filled at less-than-one month intervals o Opioid prescriptions filled at multiple different pharmacies in a short period of time 4

5 o Opioid prescriptions written by doctors other than patient s PCP Ensure the patient has a follow-up appointment with YOU as their PCP at least within the next 90 days, but preferably within 30 days o Okay to overbook if necessary to accomplish this o Consider an extended 60 minute visit, and bill a level 5 visit, in which it is documented that more than 45 minutes was spent in the care of the patient, half of which involved counseling on management of chronic pain. To prevent the patient from running out of medications before their next visit, may prescribe up to (but NO more than) a 90 day supply of medications according to the below federal guidelines: o The 90 day supply must be written as three separate monthly prescriptions with added comments / dates for when to fill each: (e.g. 1 st Rx is written as fill today, 2 nd Rx is written as do not fill until, and 3 rd Rx is written as do not fill until ) o The individual practitioner concludes that providing the patient with multiple prescriptions in this manner is SAFE and does not create an undue risk of diversion or abuse. Document number and frequency of all opioid prescription refills in YOUR clinic note (so it is clear to any other provider how much has been dispensed). Stop tramadol if initiating opiates Wean off benzodiazepines soon, with help of SSRI +/- Hydroxyzine (10-25 mg TID prn) 5

6 3. Which opiates should we prescribe in the PCC, and what is the ceiling dose? We should prescribe hydrocodone or morphine instead of oxycodone. The reason for this is that our UDS is more sensitive for detecting hydrocodone and it s metabolite, hydromorphone. o Short-acting opioids are preferred over long-acting medications. o Long-acting medications have a higher chance of developing tolerance and higher rates of overdose Our ceiling dose is 50mg of Morphine Equivalent Doses (MEDs) If patient is on a opioid OTHER than hydrocodone or morphine, please refer to our drug conversion chart and convert them over. 4. Should I prescribe short acting or long-acting opioids? According to CDC guidelines, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids. There is a higher risk for overdose among patients initiating treatment with Extended Release (ER) / Long-Acting (LA) opioids Scheduled use of ER/ LA opioids does not seem to reduce risks for opioid misuse or addiction Time-scheduled opioid use can be associated with greater total average daily opioid dosage compared with intermittent, as-needed opioid use. There is currently not enough evidence to determine the safety of using immediate-release opioids for breakthrough pain when ER/ LA opioids are used for chronic pain (outside of active cancer pain / palliative care). This practice might be associated with unnecessary dose escalation. 5. Which opiates should I AVOID prescribing in the PCC? Avoid prescribing oxycodone, because: o It has more potency mg per mg, so it tends to be a more desired recreational drug o It has higher street value (for the above reason) o It is more likely to be falsely negative in the UDS, leading physicians to believe it is not being taken (when the patient actually may be adherent to the medication) Avoid use of codeine, because it has many PD450 interactions. Methadone or Fentanyl prescriptions are NOT recommended within the PCC o Methadone and Fentanyl have VERY long half-lives, so they can accumulate to toxic levels without very close follow-up o Methadone can prolong QTc and cause Sudden Cardiac Death 6

7 o Contact Chronic Pain Task Force with questions about management of patients who present to the PCC on these medications o Chronic methadone patients with heroine addiction should be managed by specialty methadone clinics. Consider referral to the below methadone clinics (keep in mind that methadone clinics ONLY distribute methadone for addiction, NOT pain): Southside Medical Center New Day Treatment Center Alliance Recovery Center Veterans Affairs Medical Center Substance Abuse Treatment Program 2685 Metropolitan Parkway, Suite C Atlanta, GA Martin Luther King Jr Drive Atlanta, GA Swanton Way, Suite B Decatur, GA Clairmont Road Decatur, GA (404) (404) (404) (404)

8 6. How should I follow-up with patients, after opiates have been initiated? Review the SPECIFIC functional goals that the patient has set (e.g. I want to walk two blocks to the grocery store) o Considering tapering off the opioid if no observed improvement in function Reassess patient s risk-benefit profile; continue opioids ONLY for low risk patients; taper off opioids if patient is at moderate or high risk: o Risk Level o Patient Characteristics o Low Risk o Moderate Risk o No history of substance use problem, past or current o No contributory family history of substance abuse o No major or untreated mental health problems o History of substance use problem (treated) o Family history of substance abuse o Comorbid minor or past major mental health problem o High Risk o Current substance use problem o Active addiction o Major untreated mental health problem Ensure mental health screening and treatment is provided, if appropriate: o If needing SSRI or SNRI, coach and encourage patient to stay on medication long enough for it to have time to work (>8-12 weeks at effective dose) (like a cast for a broken bone) o Give the option of calling Crisis hotline if they feel worse: o Consider referring to Dr. Tamara Haynes (board certified in BOTH Internal Medicine and Psychiatry) by sending her an EPIC message with MRN of patient Ensure alternative sources of pain control are being utilized: o PT/OT o Injection Clinic o Anesthesia s Procedure Clinic / Pain Clinic for possible injection: steroid injection; nerve block o Taper off opioids if the above adjunctive measures have been provided, but are not being utilized by patient 8

9 UDS ordered at follow-up clinic visit. If UDS positive for cocaine, benzodiazepines, amphetamines, then: The patient should not be prescribed additional opioids under any circumstances. Do NOT let patient manipulate the situation by saying they used illicit drugs "just one time." Do NOT re-prescribe opioids even if their follow up UDS is negative. The patient also should be referred for addiction services. This should ALL be documented clearly in the medical record. Check the GA prescription drug registry ( at EVERY visit to ensure patient has not filled any other opioid medications or benzodiazepines (if so, they cannot receive opioids from you).taper off opioids if: o Multiple opioid prescriptions have been filled at less-than-one month intervals o Opioid prescriptions filled at multiple different pharmacies in a short period of time o Opioid prescriptions written by doctors other than patient s PCP Ensure the patient has a follow-up appointment with YOU as their PCP at least within the next 90 days, but preferably within 30 days (okay to overbook if necessary to accomplish this). To prevent the patient from running out of medications before their next visit, may prescribe up to (but NO more than) a 90 day supply of medications. o Only do so if providing multiple prescriptions in this manner does not create an undue risk of diversion or abuse o Keep in mind that a three month refill should be written as three 3 separate monthly prescriptions (e.g. 1 st Rx is written as fill today, 2 nd Rx is written as do not fill until and 3 rd Rx is written as do not fill until 9

10 7. When should I escalate doses of opiates, and what is the ceiling dose? Recall that chronic opiate therapy will likely NOT cure a patient s pain, but may improve their function Make sure that patient has set SPECIFIC goals related to their function (e.g. I want to walk two blocks to the grocery store) o If function has not improved at all with current dose, advise patient that it likely will not improve with higher doses either o Could consider a short trial of higher dose, with EXPECTATION that you will taper off if no improvement in function (document this expectation in your clinic note) Recall that any opioid given chronically will become less effective (i.e. tolerance); this effect is not an indication of necessity to increase the opioid, but rather to continue to encourage more effective non-cot adjunctive therapies: o PT/OT o Pain clinic o Injection clinic o Acetaminophen/ NSAIDs o TCAs (if no cardiac history or prolonged QTc) Review patient s medication bottles to ensure they are on their current refill, and that the pill count is appropriate; if they are not taking the appropriate amount of their current regimen, no need to increase dose o If no pill bottles available for a pill count, call patient s pharmacy to review all active/recent medications Reassess patient s risk-benefit profile; ONLY increase opioids if patient is at low risk (if moderate or high risk, this would be an indication to taper the patient off): o Risk Level o Patient Characteristics o Low Risk o Moderate Risk o No history of substance use problem, past or current o No contributory family history of substance abuse o No major or untreated mental health problems o History of substance use problem (treated) o Family history of substance abuse o Comorbid minor or past major mental health problem 10

11 o Risk Level o High Risk o Patient Characteristics o Current substance use problem o Active addiction o Major untreated mental health problem Keep in mind that the ceiling dose for opiates in the PCC is 50mg of morphine-equivalent doses (MEDs) per 24 hours. See Review of ongoing COT for those already on doses exceeding the ceiling dosages, to taper them down. IF you feel that a patient requires dosage in excess of ceiling doses, then consult the Chronic Pain Task Force for review. 11

12 8. What should I do if I inherit a patient on chronic opiate therapy? Review indication for the medication and determine if appropriate: o Bursitis and Sleep disorders [including Fibromylagia] should not be treated with COT, but with appropriate specific treatments o Most cases of chronic LBP or sciatica should not be treated with COT Is the chronic pain ongoing? For example, if patient had chronic hip, but is now s/p THR, he/she should not need the same amount of opiates as prior to surgery; begin to taper Review utilization of other important adjunctive therapies: o PT/OT o If no PT/OT, educate patient on need for daily stretching to maintain/increase function over time o IF not increasing in flexibility; strongly consider weaning off COT If appropriate indication, but too high a dosage, consider: Tapering dosage over two weeks with initiation of other therapies (this choice is most appropriate for the majority of cases) Referral to Chronic Pain Faculty Task Force for recommendations Reassess patient s risk-benefit profile; taper off opioids if patient is at moderate or high risk: Risk Level Patient Characteristics Low Risk Moderate Risk No history of substance use problem, past or current No contributory family history of substance abuse No major or untreated mental health problems History of substance use problem (treated) Family history of substance abuse Comorbid minor or past major mental health problem High Risk Current substance use problem Active addiction Major untreated mental health problem 12

13 9. When should I taper a patient off opioids? COT should be tapered off for ANY of the following: Diversion if the patient has a negative UDS for a opioid which they are supposed to be taking Remember, UDS sensitive for hydrocodone Not as sensitive for oxycodone false negatives may occur If on oxycodone, convert to hydrocodone and reassess UDS after conversion Use of street drug (e.g. + UDS for cocaine) Benzodiazepine + on UDS Alteration of prescriptions (e.g. adding "0" to amount to be dispensed) Repeat failure of other aspects of chronic pain contract such as: o Not bringing all bottles for pill count; o Not coming to appointments; o Not making progress in PT; o Getting opiate prescriptions inappropriately from other doctors Abusive language, threats of physical violence, or physical violence will not be tolerated. Any patients exhibiting such behaviors during treatment should be weaned off opioid medications. 10. How do I taper a patient off opioids? A decrease by 10% of the original dose (both long-acting and/or short-acting simultaneously) per week is usually well tolerated with minimal physiological adverse effects. Some patients can be tapered more rapidly without problems (over 6 to 8 weeks). If any questions about how to taper, call the Chronic Pain Task Force. If opioid abstinence syndrome is encountered, it is rarely medically serious although symptoms may be unpleasant. Symptoms of an abstinence syndrome, such as nausea, diarrhea, muscle pain and myoclonus can be managed with: Clonidine mg orally every 6 hours, or Clonidine transdermal patch 0.1mg/24hrs (Cataprese TTS-1 ) weekly during the taper (while monitoring for often significant hypotension and anticholinergic side effects) In some patients it may be necessary to slow the taper timeline to monthly, rather than weekly dosage adjustments. 13

14 Symptoms of mild opioid withdrawal may persist for six months after opioids have been discontinued. Consider using adjuvant agents, such as antidepressants to manage irritability, sleep disturbance or antiepileptics for neuropathic pain. Referral for counseling or other support during this period is recommended if there are significant behavioral issues. Referral to a pain specialist or chemical dependency center should be made for complicated withdrawal symptoms. Remind patient that we (PCP and PCC) will not abandon them, but will continue to pursue other therapies Call patient s pharmacy to notify discontinuing all opioids Call Grady pharmacy to flag patient s medication list to avoid opioids Document the discontinuation in your progress note 14

15 11. If a patient has had opioids discontinued in the past, when and how should the PCP reinstitute chronic opiate therapy? After 3+ months of successful monthly follow-up of patient, showing o Active use of non-cot therapy, including improved flexibility with PT/OT stretches/exercises at home o Improvement in mental and social support spheres o Multiple repeat negative UDS examinations Obtain approval by Chronic Pain Faculty Task Force Review realistic goals of treatment, which are improvement in function RATHER than control of pain Ensure patient sets SPECIFIC functional goals (e.g. I want to be able to walk two blocks to the grocery store) Detailed discussion of points of chronic pain contract, see Appendix A UDS ordered and done, prior to initiating new prescriptions Review the Georgia Prescription Drug Registry ( to ensure no other opioid Rx s have been given 15

16 12. Under what circumstances can we give opioid medications for chronic pain during a walk-in (or non-pcp) visit in the PCC? IF patient is already a PCC continuity patient AND Has a current pain contract, AND In the last 3 months has been seen their PCP, AND Our system is preventing the patient from getting their agreed upon therapy (e.g. resident pulled from scheduled clinic or didn t give enough medication until next appointment) ***If all of the above criteria are met, okay to give enough opioid mediations to coordinate care until follow-up with PCP 13. Under what circumstances can we give benzodiazepines in the PCC? If patient is on a benzodiazepine, which was NOT started by their Grady PCP, then Refer patient back to the prescriber of the benzodiazepine IF after attempting to contact prescriber, and they are not available, then consider a ONE TIME, brief taper of benzodiazepine, but only if patient has all of the following: o Positive UDS for benzodiazepine o Stable home situation o NO concurrent alcohol abuse o NO suicidal ideations o Signed chronic pain medication agreement stating they understand: They are being tapered off this medication They will NOT continue similar medication from another provider They will NOT consume alcohol or illicit drugs Counsel on withdrawal symptoms; if symptoms noted go to ECC 16

17 14. If a patient is on a opioid that we do not provide in the PCC, how do I convert it to hydrocodone or morphine? Converting existing pain therapy to morphine or hydrocodone* I. Determine the total daily dose of the current pain medication. II. Using the conversion chart, determine the Morphine Milligram Equivalent (MME) dose by multiplying the dose of the current pain medication by the listed conversion factor. III. Decrease the MME dose by 50% to determine the starting dose of morphine or hydrocodone (to account for incomplete cross-tolerance and patient-specific differences in opioid pharmacokinetics). IV. Consider patient s renal function and drug interactions in regards to further dose adjustments. Current Opioid Conversion Factor to MME Codeine 0.15 Hydrocodone (IR) 1 Hydromorphone (IR or CR; not ER) 4 Morphine 1 Oxycodone 1.5 Oxymorphone 3 Adapted from Von Korff M, Saunders K, Ray GT, et al. Clin J Pain 2008;24:521 7 and Washington State Interagency Guideline on Prescribing Opioids for Pain ( *Dose conversions are for PO to PO formulations Examples: You are meeting a patient for the first time who has come to establish care. They are currently taking Percocet (oxycodone/acetaminophen) 5/325mg four times daily. What regimen utilizing hydrocodone would you convert them to (assuming the patient has normal renal and hepatic function)? 1. Total daily dose of oxycodone = 20 mg mg x 1.5 = 30 mg morphine = 30mg hydrocodone (since morphine and hydrocodone have a 1:1 conversion factor) mg/2 = 15 mg hydrocodone q 12 hours à new starting dose of hydrocodone (use hydrocodone/acetaminophen 5/325mg TID) 4. Note: hydrocodone and morphine are equivalent in potency; therefore, if you converted to morphine you would also start at a total daily dose of 15 mg Available dosage forms on the GRADY FORMULARY: Hydrocodone/acetaminophen tablets: 5/325mg Morphine sulfate (immediate-release) tablets: 15 mg, 30 mg 17

18 15. Who is on the Chronic Pain Task Force? Therese Vettese, MD, PIC Kristi Quairoli, Pharm D, PIC How do I approach the patient with a persistently negative UDS? Educate the patient that a negative UDS suggests they may not be taking the medications as prescribed Perform a pill count to determine that patient is not taking more medications per day than prescribed If on other types of opioids (e.g. oxycodone) switch to hydrocodone, as it is better detected in the UDS (refer to drug conversion table in this document) Give patient the expectation that if they have more than 3 negative UDS results, you will need to taper them off opioids (document this in your note) 18

19 17. What do I need to know about the Urine Drug Screen? We should order the UDS under the name Drug Screen-Pain Management. This ensures that the sample obtained is from the patient and has not been mistaken for a different patient. DRUG SCREEN PAIN MANAGEMENT [LAB3083] AMPHETAMINES BENZODIAZEPINES BARBITURATES COCAINE OPIATES PHENCYCLIDINE METHADONE METHAQUALONE PROPOXYPHENE FENTANYL Why is hydrocodone better detected in the UDS than oxycodone? o Our urine drug immunoassay screen has antibodies that detect morphine. A positive means the concentration has exceeded the 300 ng/ml morphine cutoff. o The antibody in our test reacts weakly with oxycodone (i.e. it takes an oxycodone urinary concentration of 2550 ng/ml to produce a positive signal). o Our UDS immunoassay is more sensitive for detecting hydrocodone; a concentration of about 250 ng/ml will trigger a positive result. Also, hydrocodone is metabolized to hydromorphone, which also reacts; a concentration of about 500 ng/ml produces a positive signal. Drug Detection and Elimination Times: Note: The data for detection times are estimates and vary by individual, dose, frequency of use, and metabolism. Sources: ARUP Laboratories Mayo Medical Laboratories 19

20 Amphetamine-Type Stimulants Limit of Quant (ng/ml) Detection Time (up to) Amphetamine 50 3 days Methamphetamine 50 3 days 3,4-Methylenedioxyamphetamine (MDA) 50 2 days 3,4-Methylenedioxymethamphetamine (MDMA) 50 2 days Phentermine 50 Ephedrine/pseudoephedrine Not quantitated 5 days Barbiturates Long-Acting Phenobarbital days Intermediate-Acting Butalbital days Amobarbital days Short-Acting Pentobarbital days Secobarbital days Benzodiazepines Long-Acting Diazepam 100 Nordiazepam 100 Intermediate-Acting Alprazolam 100 Lorazepam 100 Oxazepam 100 Temazepam 100 Chlordiazepoxide 100 Clonazepam 100 Flunitrazepam 50 Short-Acting Triazolam days 5 days 2 days 20

21 Flurazepam 100 Buprenorphine Limit of Quant (ng/ml) Detection Time (up to) Buprenorphine days Norbuprenorphine days Cocaine & Metabolite Cocaine 50 <1 day Benzoylecgonine 50 5 days Fentanyl Fentanyl days Norfentanyl 1 3 days Ketamine Ketamine 25 2 days Norketamine 25 2 days Lysergic Acid Diethylamide (LSD) LSD 0.5 <1 day 2-Oxo-3-hydroxy-LSD 5 5 days Marijuana/Cannabis (THC-COOH) Single Use 3 3 days Moderate Use (4 times per week) 5 days Heavy Use (daily) 10 days Chronic Heavy Use 30 days Methadone Methadone days EDDP (methadone metabolite) days 21

22 Methaqualone Methaqualone days Opiates 6-MAM day Morphine days Codeine days Hydrocodone days Hydromorphone days Oxycodone days Oxymorphone days Phencyclidine Phencyclidine 25 8 days Propoxyphene Propoxyphene days Norpropoxyphene days Questions: call the Grady Clinical Laboratory Customer Service Reference Laboratory Testing Laboratory Administration Dr. Dave Koch, Director, Clinical Chemistry & Toxicology After Hours Lab Supervisor

23 Patient/Caregiver s Name: Patient-Provider Chronic Pain Management Agreement Pt. MRN: Pt. Address: Phone Number: Primary Care Provider: Pharmacy Name: Pharmacy Number: I agree to follow these rules to be considered for opioid therapy. INITIALS (of patient to confirm understanding and agreement): Following My Doctor s Instruction for Medications and Other Treatments I will follow all of my doctor s instructions for taking medicines and for other treatments. I understand that it may take time to find the right type and amount of medicine to help decrease my pain. I will work with my doctor to find the right combination that limits my pain and helps me to function. I will use my medicines only as my doctor orders. I will not give or sell my medicines to other people. Doing My Daily Part and Keeping My Appointments I will do my part with frequent daily stretches and strengthening exercises. I will take my other medications which are part of my pain management. I will make and keep appointments for prescription re-fills. Getting My Opioid Prescriptions I will get opioids from my primary care doctor only, and only on the usual follow-up day. I will not ask for opioids from other doctors in the clinic, Emergency Room, or at other clinics or hospitals. I will fill my prescriptions at only one pharmacy (see above). Communicating / Coordinating Pain Management Medication Use If I do get opioid pain medicines from another doctor for a reason other than my chronic pain (for example, if I have an injury), I must let my primary care doctor know. I give permission for my doctor to independently look for and see my pain related medical records from other medical facilities/pharmacies to assure coordination of my pain management; my doctor must let me know if there are any problems found. By signing this form, I understand and agree to follow these rules. *** SEE Page 2 Signed (Patient/doctor): / Date: 23

24 Patient-Provider Chronic Pain Management Agreement Patient/Caregiver s Name: INITIALS (of patient to confirm understanding and agreement): I agree to follow these rules to be considered for opioid therapy. No Replacement Medicines I will be responsible for all prescriptions my doctor gives me. If I lose my prescription or if it is stolen, my doctor will not write another until my usual follow-up appointment. Bringing ALL Prescription Bottles to Monthly Appointments I will come to my usual clinic appointment every month unless my doctor says otherwise. I will bring ALL my recent prescription bottles with me for every visit. No Alcohol or Street Drugs I will not drink any alcohol (wine, beer or liquor) while I am taking this medicine. I understand that I cannot take any kind of street drug. I will not take other medications my doctor tells me not to take. At all visits, my doctor has the right to give blood or urine tests to check for drugs; I will come 1 hour early to clinic to have my urine checked before my appointment with my doctor. Broken agreement If I break this agreement, then I will not be able to receive opioids from the clinic. Examples of breaking this agreement include (but are not limited to): diverting medication (selling my medication or giving my medication to another person); using street drugs; repeatedly not keeping my appointments; not providing an appropriate urine/blood test on the day is was ordered; not actively trying all other therapies, including daily physical therapy, to help my pain. Communication with My Doctor if I can t function or if pain is too much I will let my doctor know if I cannot do what I need to do. I will let my doctor know if my pain is increasing. I know I can contact my doctor by leaving a message at this phone number: By signing this form, I understand and agree to follow these rules. ***SEE Page 1 Signed (Patient/doctor): / Date: 24