A checklist for chronic opioid therapy
Both the physician and the patient should initial each point.
| Provider initials | Patient initials | Shared responsibilities |
|---|---|---|
| 1 We talked about how my pain affects me and how opioids may help me function. We agreed to work toward the following goals: (Table 1, elements 1, 4, and 8) Goal #1: Goal #2: Goal #3: | ||
| 2 We talked about other treatment choices. We decided together to use opioids, but my doctor also recommends starting or continuing the following: (Table 1, elements 2, 5, and 8) Physical therapy: Yes/No Talk therapy: Yes/No Exercise: Yes/No Counseling: Yes/No Massage, chiropractor treatment, acupuncture: Yes/No Other pain medications: Yes/No | ||
| 3 We talked about possible side effects and the risk of overdose. We also talked about what to do if this happens. (Table 1, element 3) | ||
| 4 We agreed to be honest with each other. We both have the same goal—to safely control my pain. (Table 1, element 4) | ||
| 5 We talked about the cost of my medication and which drugstore I will use. We also talked about other choices if they become too expensive. (Table 1, elements 3 and 6) | ||
6 We agreed that opioids can be dangerous, especially if used in the wrong way. For my safety, we agreed that my doctor needs to monitor my pain treatment. This may include: (Table 1, element 9)
| ||
| 7 We agreed that I would take only the number and type of pills prescribed to me. We will work together to change them if they are not meeting our agreed-upon goals. (Table 1, elements 7 and 9) | ||
| 8 I will tell my doctor about all the pills I am taking and any new medication given to me by someone else. (Table 1, element 2) | ||
| 9 My doctor has the right name, address, and phone numbers for me. I will let my doctor know if they change. (Table 1, element 6) | ||
| 10 If I have a problem, or if my pain medication is not working, I will talk to my doctor before I do anything different with my pills. (Table 1, element 9) | ||
| 11 I agree to take my pills the way the doctor tells me. If I do not understand the directions, I will ask questions. (Table 1, element 7) | ||
12 My doctor explained that opioids are even more dangerous when they are mixed with other drugs or alcohol or used in the wrong way. For safety, I understand that I should not: (Table 1, elements 3, 5, and 6)
| ||
| 13 I understand that my pills are for me only. I will keep them in a safe place away from children and other people. I will also get rid of leftover pills only in the way my doctor or pharmacist teaches me. (Table 1, element 3) | ||
| 14 I will tell my doctor right away if I am pregnant. I know that my medications may need to change to keep me and my baby safe. (Table 1, elements 3 and 9) | ||
| Physician responsibilities | ||
| 15 I will listen to my patient’s stories about living with pain. I will keep their personal goals in mind when recommending treatment. (Table 1, element 5) 16 I will keep learning about how to treat pain and recognize when opioids are causing more harm than good. (Table 1, element 5) 17 I will make sure my patient has the right phone numbers for my office and the hospital. (Table 1, element 9) 18 My office and I will be available to my patients when they need help. (Table 1, element 9) 19 I will make sure my patient knows my office rules about how and when to ask for refills. (Table 1, element 7) 20 I will teach my patients how to take their pills safely. I will have them show me to be sure they are doing it right. (Table 1, element 7) 21 If I believe opioids are no longer safe or helping my patient, I will carefully stop prescribing them and use other treatments. (Table 1, elements 5 and 9) |