Kennebec Region Health Alliance

It has been explained to me that the use of opioid drugs (for example, methadone, hydromorphone, oxycodone, fentanyl, morphine, hydrocodone, tramadol) leads to a higher risk of accident, injury, falls, car accidents, breathing problems (including not breathing), heart disease, accidental overdose and death.

• I understand that our goal is improved function and not total relief of pain.
• I know that higher doses of these drugs lead to even greater risks.
• I know that there are not good studies that show that these drugs help people with chronic pain.
• I know that having these drugs may increase my risk of being the victim of a crime.
• I know that these drugs sometimes lead to dependence and misuse.
• I know that up to 35% of people using these drugs may develop addiction.
• I know that if I have a history of addiction of any kind (including alcohol) I should not take these drugs.
• I know that using alcohol with opioids is risky and I understand that my clinician may take me off opioids if he/she feels that my use of alcohol places me at risk.
• I know that the use of certain anxiety drugs, known as benzodiazepines (“benzos”), along with opioids is dangerous and that my clinician and I should avoid the use of these drugs while I am receiving prescriptions for opioid drugs. Examples of benzodiazepines include alprazolam, clonazepam, diazepam and lorazepam.
• I know that side effects of these drugs include sedation, constipation, reduced hormone levels and reduced sex drive, personality changes, falls and osteoporosis.
• I know that opioids should not be used routinely for headaches, fibromyalgia, chronic back pain and Chronic Regional Pain Syndrome (Reflex Sympathetic Dystrophy).
• I know that my clinician will be checking on all of my controlled drug prescriptions through the Prescription Monitoring Program of the Office of Substance Abuse.
• I know that if I am on high dose opioids (over 100 morphine equivalents daily) these risks and side effects are more common. I know that my risk of accidental overdose is increased and my risk of premature death is also significantly increased.
• I know that if I am on high dose opioids I may need additional testing to assess my risk of the drug causing a respiratory arrest (where I stop breathing).
• I know that if I am on high dose opioids my clinician and I will work to reduce my dose to a less risky level.
• I know that while I am on high dose opioids my clinician and I should discuss the possibility of a prescription for naloxone for treatment of overdose.

My clinician, ____________________, and I have tried other more effective and safer treatments, such as physical therapy, osteopathic therapy, exercise, weight loss and counseling and they have not helped enough. We have also tried non-opioid drugs like acetaminophen, anti-inflammatory drugs, some anti-depressant drugs, and some anti-seizure drugs, which have been shown to work better and are much safer. I understand the risks described here and I know that by taking opioid drugs I accept all of these risks.

Patient Name: _______________________________ Patient DOB: ___/___/_____

Patient/Guardian Signature: ____________________________ Date: ___/___/______

Clinician Signature: ___________________________ Date: ___/___/______

Adapted from the Bangor Area Workgroup informed consent document, 2015