Creating and Using a Patient Provider Agreement

Notes to Consider

It is important that opioid therapy be offered as part of a larger treatment plan that may encompass other, non-pharmacological interventions.

These may include:

  • Regular exercise.
  • Stress management techniques.
  • Meditation.
  • Physical Therapy.
  • Cognitive-behavioral Therapy.

The treatment plan should also include a review of expectations, including:

  • Regular attendance at all appointments.
  • Pill counts.
  • Urine drug testing.
  • The use of only one provider and pharmacy to receive prescription medications.
  • Refill and renewal policies.

Questions to Ask Patients

Functional Status
  • Are you able to cook/clean/shop for yourself?
  • Do you use assistive devices?
  • Do you have help at home?
  • Where do you live?
  • Are you stably housed?
  • Are there stairs to enter or within your home?
  • Do you feel safe at home?
  • Are you responsible for the care of children?
  • Are you in a relationship?
  • Do you feel safe in your relationship?
Support Network
  • Who is in your network of helpful/supportive people?
  • How do you get around and to appointments?
  • Are you employed?
  • Is your income enough to meet your basic needs?
Mental Health
  • Do you have a history of psychiatric hospitalization?
  • Do you have a a history of suicidal ideation or attempts?
  • Have you ever received mental health treatment?
  • Are you currently receiving mental health treatment?
Substance Abuse
(street drugs, alcohol, Rx Medications)
  • Do you have a history of substance abuse?
  • Are you currently abusing any substances?
  • Are you responsible for the care of children?
  • What is the highest grade in school that you completed?
  • Are you able to read and write?
  • Have you ever been in jail or prison?
  • Do you have any current legal issues?
  • Do you belong to a church or other spiritual organization?


Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005 Mar-Apr;6(2):107-12.
Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med 2011;12(6):890-897.