Kennebec Region Health Alliance

Promoting Healthy Communities Since 1997

Informed Consent for Opioids for Chronic Pain

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

Contact Us

Kennebec Region Health Alliance
10 Water Street, Suite 202
Waterville, ME 04901
(207) 873-9842

Compliance Helpline
(207) 621-9870