CONTROLLED 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]