A controlled substance agreement, also called a pain management or opioid treatment agreement, is the plan a clinician and patient make together for long-term treatment with an opioid, a stimulant, or a benzodiazepine: the goals, the risks, and what each of them commits to. Copy the free template, see a knee arthritis and an adult ADHD example, and check what goes in each part.
Blank controlled substance agreement template
FreeCONTROLLED SUBSTANCE AGREEMENT A shared plan for long-term treatment with an opioid, stimulant, benzodiazepine, or other controlled medicine Patient: [Name and date of birth] Clinician: [Name, credentials, practice, and phone] Date: [Date signed] OUR GOALS Condition being treated: [Diagnosis, and how long it has lasted] What we've tried: [Other treatments, and how well each worked] What I want to be able to do: [Two or three goals, such as work a full shift, walk farther, sleep through the night, or study for longer] How we'll measure it: [The score or scale we use, today's result, and the target] Treatments that continue: [Exercise, therapy, other medicines, or devices used alongside this medicine] THE MEDICINE Name and dose: [Medicine, strength, how many, and when] Daily total: [For an opioid, the morphine milligram equivalents a day, or not applicable] Each prescription lasts: [Number of days] Taking it: [I'll take it as prescribed, and talk to my clinician before I change the dose or the timing] BENEFITS AND RISKS WE DISCUSSED Expected benefits: [What this medicine should help with, and how soon] Common side effects: [Constipation, drowsiness, nausea, poor appetite, trouble sleeping, faster heart rate, or others that fit this medicine, and what to do about each] Serious risks: [Overdose and slowed breathing, physical dependence and withdrawal, addiction, falls, or others that fit this medicine] Alcohol and other sedatives: [Alcohol, sleeping pills, benzodiazepines, cannabis, and other medicines that add to the risk, and what we agreed] Driving and work: [When I shouldn't drive or use machinery, such as the first week, after a dose change, or when drowsy] Pregnancy: [Plans and contraception, and to tell my clinician if I could be pregnant, or not applicable] NALOXONE AND SAFETY AT HOME Naloxone: [Prescribed or offered, the form, and where it's kept, or not needed and why] Who can give it: [The people at home or nearby who know where it is and how to use it] Storage: [A lockbox or locked cabinet, out of reach of children, teenagers, visitors, and pets] Disposal: [Pharmacy or community take-back for any medicine I no longer need] Sharing: [I won't share, sell, or trade this medicine, or take anyone else's] PRESCRIPTIONS AND REFILLS One prescriber: [The clinician or team who prescribes it, and who covers when they're away] One pharmacy: [Pharmacy name and phone] Other prescribers: [I'll tell my clinician about any controlled medicine from another clinician, a dentist, a surgeon, or an emergency department] Refills: [How to ask, how many days' notice, and what happens if I run out early] Lost or stolen medicine: [Tell the clinic the same day, and how we'll handle it together] Travel and breaks: [How to plan refills before a trip, a holiday, or a move] ROUTINE SAFETY CHECKS We do these for everyone on this kind of medicine, not because of anything about me. Prescription monitoring program: [Checked today, and how often after] Urine drug testing: [At the start and at least once a year, and what happens if a result is unexpected] Follow-up visits: [First review date, then how often] At each visit: [Goals and scores, side effects, and checks that fit the medicine, such as blood pressure, heart rate, weight, breathing during sleep, or mood] IF THE PLAN ISN'T WORKING Review: [If my goals aren't met or the risks grow, we review the plan together before anything changes] Changing the dose: [Any reduction is slow, planned with me, and supported; the medicine won't be stopped suddenly] If problems with use develop: [My clinician will offer treatment, such as medicine and counseling, and keep caring for me] Changing or ending this agreement: [Either of us can ask to review it at any time; stopping this medicine doesn't end my care at this practice] MY CLINICIAN'S COMMITMENTS [Take my symptoms seriously, offer other treatments, respond quickly to side effects, explain any change before making it, and keep caring for me whatever happens with this medicine] MY COMMITMENTS [Take the medicine as agreed, use one prescriber and one pharmacy, keep it locked away, come to my visits, and tell my clinician about problems early] SIGNATURES Patient: [Signature, printed name, and date] Clinician: [Signature, printed name, credentials, and date] Copy given to the patient: [Date] Next review of this agreement: [Date, such as in 6 or 12 months, or after a major change]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice; a 61-year-old moves to a long-acting opioid while he waits for a knee replacement
Walter Brooks, 61, born March 14, 1965. Clinician: Dr. Priya Nair, Riverside Family Practice. Signed September 28, 2026. Condition: severe osteoarthritis of the right knee, bone on bone on X-ray; right knee replacement booked for March 2027. Tried: acetaminophen 1 g 3 times a day, which continues; diclofenac gel; 8 weeks of physical therapy; a steroid injection in July that helped for 6 weeks. No anti-inflammatory tablets since a bleeding stomach ulcer in 2023. Duloxetine caused nausea and was stopped after 2 weeks. Goals: finish a full shift as a school custodian, walk the dog around the block, sleep 6 hours, and keep up his exercises before surgery. Measure: PEG score 7.7 today; aim for 30% better, 5.4 or lower.
For 6 weeks, immediate-release morphine 5 mg up to every 4 hours helped him walk farther without drowsiness. He took 6 doses most days, 30 mg in all, and still woke at 3 a.m. when it wore off. From today: morphine extended-release 15 mg every 12 hours, the same daily total of 30 morphine milligram equivalents, with no extra doses. 28-day supply. Side effects: constipation, so senna at bedtime from today; drowsiness; nausea. Serious risks: slowed breathing and overdose, more likely with his sleep apnea; physical dependence, so it must never be stopped suddenly; addiction, which can develop at any dose; and falls. Alcohol: he has 2 beers on Saturdays and agreed to stop while on morphine. No sleeping pills, benzodiazepines, or cannabis. No driving for the first week, or whenever he feels drowsy. He’ll keep using his CPAP every night.
Naloxone nasal spray 4 mg, 2 doses, prescribed today because of his sleep apnea, and kept in the kitchen drawer. His wife, Linda, was shown how to give it, and their son knows where it is. Storage: a lockbox in the bedroom closet, since their grandchildren, ages 4 and 7, visit every Sunday. Disposal: his 14 leftover immediate-release tablets go to the pharmacy take-back bin today. He won’t share his medicine or take anyone else’s.
Prescriber: Dr. Nair; Dr. Okafor covers when she’s away. Pharmacy: Riverside Pharmacy, 555-0148. He’ll tell Dr. Nair about any opioid from the surgeon, a dentist, or an emergency department. Refills: ask through the patient portal 3 working days ahead; a new prescription every 28 days. Lost or stolen medicine: call the same day, and Dr. Nair will plan with him so he doesn’t go into withdrawal. Prescription monitoring program: checked today, showing only this practice’s morphine; checked before each prescription. Urine drug test: today, as for every patient on long-term opioids, then once a year. An unexpected result means a conversation and a lab confirmation. Visits: in 2 weeks, then every 4 weeks until surgery.
If his goals aren’t met at the 3-month review, or the risks grow, they review the plan together; the dose won’t go up to chase a pain score. Any reduction will be slow and supported. If problems with use develop, Dr. Nair will offer treatment such as buprenorphine and keep caring for him. Around surgery: the surgical team prescribes any opioid for the first 2 weeks and tells Dr. Nair. Then Dr. Nair tapers the morphine over 4 to 8 weeks as the knee recovers, aiming to stop.
Dr. Nair: take his pain seriously, keep the other treatments going, see him promptly about side effects, explain any change before making it, and keep caring for him whatever happens with the morphine. Walter: take it as prescribed, use one pharmacy, keep it locked away, keep using CPAP, no alcohol, and come to every visit. Signed by both on September 28, 2026. Copies to Walter and, with his consent, to the surgeon’s office. Review the agreement after surgery, or in 6 months.
October 12, 2026. PEG 5.0, down from 7.7. Walks the dog for 15 minutes most days, sleeps 6 hours, and finished 4 of 5 shifts last week. No daytime drowsiness; bowels regular on senna. CPAP every night, and no alcohol. Urine test from the first visit: morphine, as expected, and nothing else. Monitoring program: no other prescribers. Naloxone picked up, and Linda showed Dr. Nair how she’d give it. Decision: goal met; continue morphine extended-release 15 mg every 12 hours, 30 MME a day, with no increase. Next visit in 4 weeks. The agreement and the taper plan for after surgery sent to the surgeon and the anesthesia team.
College health service; a 34-year-old nursing student moves her stimulant prescription to campus
Jordan Ellis, 34, born May 22, 1991, second-year nursing student. Clinician: Morgan Shaw, nurse practitioner, campus health service. Signed January 12, 2026. Condition: ADHD, combined presentation, diagnosed at 32 by a psychiatrist in her home city after a full assessment; the report is on file. Lisdexamfetamine 40 mg every morning for 18 months, with good effect. She moved for school, and the health service takes over prescribing. Continuing: a weekly planner, a study group, and ADHD coaching through the counseling center. Goals: read and take notes in 2-hour blocks, hand in every assignment on time, pass pharmacology, and sleep 7 hours. Measure: her own focus rating, 7 of 10 now, and late assignments, aiming for none.
Lisdexamfetamine 40 mg, 1 capsule by 9 a.m.; 30-day supply. Benefits: steady focus through the day. Side effects: less appetite, so breakfast before the capsule and a planned lunch; trouble sleeping if taken late; dry mouth; a faster heart rate and higher blood pressure; anxiety. Serious risks: misuse and dependence; rarely, mood changes or psychosis. Caffeine: 1 coffee a day, no energy drinks. Alcohol: the stimulant can hide how drunk she feels, so no more than 2 drinks on a night out. Pregnancy: she has an IUD and will tell Morgan before trying to conceive, to review the medicine first. Baseline: blood pressure 118/76, heart rate 74, weight 63 kg. No fainting, chest pain, or palpitations, and no family history of sudden death before 50.
Naloxone: offered and accepted. Fake “Adderall” pills sold on campus can contain fentanyl or methamphetamine, so she’ll take only capsules from her pharmacy; the kit is in her bag, and her roommates know where. Storage: a small lockbox in her room. She shares an apartment with 2 classmates, who have asked for pills before exams; she’ll say hers are counted and locked away, and she won’t share or sell them. Prescriber: Morgan Shaw, with Dr. Lee covering. Pharmacy: the campus pharmacy. Refills: ask through the portal 5 days ahead; no early refills without a visit. Lost or stolen medicine: call the same day, and they’ll decide together what happens next. Summer: video visits continue while she’s enrolled and living where the clinic’s clinicians are licensed; if not, a handover letter to a clinician near home.
Prescription monitoring program: checked today; lisdexamfetamine 40 mg each month from her psychiatrist only, last filled January 2. Checked before each prescription. Urine drug test: today, as for every student starting a controlled medicine at the health service, then once a year. Visits: every 3 months, with blood pressure, heart rate, weight, sleep, and mood; sooner after any dose change. If the plan isn’t working, they review it together. If problems with use develop, Morgan will offer treatment and keep seeing her. She can stop at any time; no taper is needed, though she may feel tired or low for a few days.
Morgan: prescribe on time, ask about side effects at every visit, adjust the plan with her around clinical placements and exams, and write a handover letter when she graduates. Jordan: take it as agreed, keep it locked away, use one pharmacy, and call before changing how she takes it. Signed by both on January 12, 2026; copy to Jordan. Review the agreement in 12 months.
April 13, 2026. Focus 6 of 10. On 12-hour clinical placement days the capsule wears off by 2 p.m. During exam week she took a second capsule on 2 days and ran out 2 days early, and told Morgan before being asked. No chest pain or palpitations; sleeps 6 to 7 hours; eats 3 meals, with less appetite at lunch. Blood pressure 122/78, heart rate 82, weight 62 kg. Urine test from January: amphetamine, as expected with lisdexamfetamine, and nothing else. Monitoring program: only this clinic’s prescriptions. Under the agreement, this is an honest report and a dose that no longer covers her day, not a breach. Decision: increase to lisdexamfetamine 50 mg every morning from today, with a new 30-day prescription; no extra capsules on her own, and a call before any change. Review in 4 weeks, with blood pressure and heart rate.
Why the medicine is being used, what it has to do better than the treatments before it, and what the patient wants to be able to do. The goals are what you judge the medicine by at every visit.
Avoid: A goal of “no pain.” Long-term pain rarely goes to zero on any medicine. Aim for function and a realistic change, such as a score 30% better.
The exact medicine and dose, and a record of the conversation about what it can and can’t do.
Avoid: A printed list of risks with no conversation. Note what you explained, the patient’s questions, and what you agreed about alcohol and driving.
How the household stays safe: naloxone with any long-term opioid, especially at higher doses, with sleep apnea, or alongside a benzodiazepine; locked storage; and disposal.
Avoid: The bathroom cabinet. It’s the first place visitors and teenagers look. Agree on a lockbox or a locked drawer.
Who prescribes, where it’s filled, and what happens when the timing goes wrong.
Avoid: “Lost medicine will not be replaced under any circumstances.” A blanket rule can push someone into withdrawal. Say the patient calls the same day, and you decide together what happens next.
The checks you make for everyone on the medicine, explained as routine, so no patient feels singled out.
Avoid: Treating a screening result as proof. Office urine screens miss some drugs and react to others, so ask the patient and confirm with the lab before deciding anything.
What happens when the goals aren’t met, the risks grow, or a commitment is broken: a review together, not a dismissal.
Avoid: Stopping suddenly. After long-term opioid use, an abrupt stop brings withdrawal and uncontrolled pain, and can push someone toward street drugs and a higher risk of overdose. Taper slowly, with support.
What each side promises, in plain words, and the signatures that make it a plan you share.
Avoid: Commitments from the patient only. With nothing on the clinician’s side, it reads as a list of conditions, not a shared plan.
Pages of “will result in discharge” tell the patient you expect the worst, and most sign without reading. Write a two-way plan in plain words, and go through it together.
A pain score on its own gives you no way to judge the medicine. Add goals in daily life, such as a full shift or a walk, and check them at every visit.
Testing only the patients who “seem” risky is unfair and misses real risk. Make the monitoring program check and urine testing routine for everyone, and say so in the agreement.
An unexpected urine result, an early refill, or a missed visit is a reason to talk and review the plan. Current guidance warns against dismissing patients for it: it cuts them off from care when risk is highest.
Prescribe or offer naloxone with long-term opioids, and name who at home can give it. Someone who has overdosed can’t give it to themselves.
Vero Scribe drafts the agreement in your template from the visit, with the patient’s consent, or from your dictation: the goals you agreed, the medicine and dose, the risks you discussed, and the plan for naloxone, refills, and checks. You review and edit every section, then copy it into your record or export it to Word or PDF for you both to sign. Vero works in 60+ languages.
A written plan between a clinician and a patient for long-term treatment with a controlled medicine: most often an opioid for pain, but also a stimulant for ADHD or a benzodiazepine. It sets out the goals, the dose, the risks, naloxone, how prescriptions and refills work, the routine checks, and what each side commits to. It’s also called a pain management agreement, an opioid treatment agreement, or a patient-provider agreement. “Agreement” has replaced the older “pain contract.”
Goals in daily life, not only a pain score; the medicine and dose, and for an opioid the morphine milligram equivalents a day; the benefits and risks, including overdose, dependence, alcohol, and driving; naloxone and who at home can give it; one prescriber and one pharmacy; refills and lost medicine; safe storage and disposal; routine prescription monitoring program checks and urine drug tests; follow-up visits; what happens if the plan isn’t working; and both sides’ commitments and signatures.
It depends on where you practice. Some regulators, insurers, and organizations require a written agreement for long-term opioid treatment; others recommend one or leave it to you. Even where it isn’t required, the conversation it records is expected: goals, benefits and risks, naloxone, and a plan for monitoring. Check your regulator’s rules and your organization’s policy.
It should lead to a conversation and a review, not an automatic discharge. An early refill, a missed visit, or an unexpected urine result can have many explanations. The clinician talks it through, confirms any test with the lab, and changes the plan if needed: more frequent visits, smaller supplies, a slow taper, or treatment for opioid use disorder. Current guidance, including the 2022 CDC guideline, warns against dismissing patients over a test result and against stopping opioids suddenly.
Because testing only the patients who seem risky is unfair and misses real risk. A test at the start and at least once a year shows whether the prescribed medicine is there, and finds other substances, such as fentanyl, that change the safety plan. Explain why you test, ask the patient what it will show, and confirm an unexpected result with a lab test before acting on it.
Many practices use one for any long-term controlled medicine. For a stimulant, it covers heart rate, blood pressure, sleep, appetite, and never sharing or selling the medicine. For a benzodiazepine, it covers falls, memory, driving, the danger of mixing it with opioids or alcohol, and a slow taper when it’s time to stop.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Complex pain histories, function, and treatment response, drafted for your review.
Assessments, follow-up notes, and care plans, drafted for your review.
The visit captured, the note drafted, and follow-up kept in view.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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