The Key Elements of a Preamble to an Opioid Agreement

Michael Schiesser, MD

Prescription opioids are not the only controlled substance with a risk for abuse, misuse, and diversion, but they have a readily achievable threshold for lethal toxicity. They are the source of widespread patient-safety problems like addiction and overdose, excess resource utilization, and disability.

One of the keys to patient safety is communication. Providers who treat chronic illness with medications that are liable to be abused struggle to balance patient safety with issues of care-management efficiency. I find that if “it takes a village” to raise kids, it takes a well-aligned organization (not just one physician) to achieve outcomes of provider satisfaction, care efficiency, and patient safety. For many providers, communicating norms and expectations can be challenging. Additionally, communicating medication limits or agreements can result in patients feeling “singled out” or misinterpreting the purpose of the discussion. For this reason, I support universal delivery of pain agreements with companion video narration, so that key points can be meaningfully identified, efficiently delivered, and universally understood—assuming that the patient has an opportunity to ask questions.

Opioid agreements may differ significantly from practice to practice and across states. For the opioid agreement I use with patients (not included here), I use this six-point preamble to introduce important concepts:

  • Working together. This agreement was created to keep your care safe and avoid confusion. Talk with your provider if you have questions before signing it. The medications you are prescribed are sometimes not used properly. This can cause serious problems. Pain medications (“opioids”), anxiety medications, and medications for attention deficit disorder are all considered high-risk.
  • What problems could develop? Sometimes when patients use these medications for months or years, they find the medicine becomes less effective. Taking more than is instructed on the bottle can place you at risk for overdose and other problems. Dependence means having withdrawal symptoms if you stop taking the medication. If you can’t control how much you take, or if you are constantly thinking about the medication, you have an addiction.
  • To avoid serious problems, never take more than the maximum daily dose in any 24-hour period. Also, pain medication can cause sleepiness, fractures, or death. Pain medications used over time can also lead to worse pain when you try to stop.
  • High risk! Thousands of people die each year from prescription overdose. Combining pain medications with anxiety medications, sleeping pills, cold medicine, or alcohol increases the chance of death. Do not mix or use these drugs in any way not directed by your provider. These medications can also make driving more dangerous.
  • You must sign the form. You need to follow this agreement to be a safe candidate for these medications. There may be other issues that lead your provider to recommend safer alternatives. Signing the form doesn’t mean the provider will necessarily prescribe you the medications. However, avoiding the agreement is not an option if you have been asked to sign in order to receive these medications. Your provider may recommend weaning off of medications; if dependence is interfering with your care, your provider may also recommend treatments for dependence. Any violations of this agreement will impact your provider’s care plan.
  • We might share this agreement. By signing this, you are giving us permission to share this agreement with emergency departments, urgent-care centers, and other providers.
  • You might ask, “If my care changes as a result of this agreement, and I disagree with that, what do I do next?” If you feel you have been impacted by this agreement and would like reconsideration, we invite you to submit a written appeal explaining your circumstances. Any appeal will be reviewed by at least two staff members and may take three to seven days for a response. 

These six elements fit nicely on one page, and I recommend placing them behind a plastic sheet protector, because the agreement itself fits on one double-sided page. When I show a short video presentation to my patients, the video prompts them to initial each of the main sections as they are explained, and then to sign the agreement.

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Dr. Michael Schiesser is an addiction specialist with Evergreen HealthCare, and serves on the quality committee for Evergreen Health Partners. He is an energetic advocate for sensible strategies to support organizations and providers in prudent clinical care. To learn more about how physicians can make a difference in opioid addiction, visit