Fillable Printable Form 252-095-000
Fillable Printable Form 252-095-000
Form 252-095-000
Department of Labor and Industries
PO Box 44291
Olympia WA 98504-4291
www.Opioids.Lni.wa.gov
OPIOID TREATMENT
AGREEMENT
Worker’s name
Claim number
Opioid (narcotic) treatment is used to reduce pain and improve what you are able to do each day.
Along with opioid treatment, other medical care may be prescribed to help improve your ability to do daily activities. This
may include exercise, use of non-narcotic analgesics, physical therapy, psychological counseling, or other therapies or
treatment. Vocational counseling may be provided to help your efforts to return to work.
I, ___________________________________________, understand that I must comply with this agreement forcontinued
pain treatment with Dr. __________________________________.
1.I have the following responsibilities:
a.Take my medications onlyat the dose and frequency
prescribed.
b.Won’tincrease or change my medications without the
approval of this provider.
c.Actively participate in Return to Work (RTW) efforts
and in any program designed to improve function
(including social, physical, psychological and daily or
work activities).
d.Won’task for opioids or any other pain medicine from
another provider. This provider will approve or
prescribe all other mind- and mood-altering drugs.
e.Inform this provider of all other medications that I am
taking.
f.Fillall medications from one pharmacy, when
possible. By signing this agreement, I give consent to
this provider to talk with the pharmacist.
Pharmacy:________________ Phone:___________
g.Protect my prescriptions and medications. Only one
lost prescription or medication will be replaced in a
single calendar year. I will keep all medications away
from children.
h.Agree to participate in psychiatric or psychological
assessments, if necessary.
i.Won’tuse illegal or street drugs, or alcohol. This
provider may ask me to follow through with a
program to address this issue. Such programs may
include the following:
•12-step program and securing a sponsor.
•Individual counseling.
•Inpatient or outpatient treatment.
•Other: ____________________________
2.In the event of an emergency, I or my representative
will contact this providerwho will discuss the problem
with the emergency room or otherdoctor. I am responsible
for requesting a record transfer to this provider.
3.I consent to random drug testing and pill counts.
4.This provider will check the state’s prescription
monitoring program database to verify my opioid
prescription history.
5.I will keep my scheduled appointments,or if
necessary, cancel my appointment at least 24 hours before
the appointment.
6.Thisprovider willstop prescribing opioids or change
my treatment plan if:
a.I don’tshow any improvement in function.
b.I behave in a way that is not consistent with my
responsibilities outlined in #1.
c.I give away, sell, or misusethe opioid medications.
d.I develop rapid tolerance or loss of improvement
from this treatment.
e.I get opioids from another provider.
f.I don’t cooperate when asked to get a drug test.
g.I develop an addiction problemfrom opioid use.
h.I experience a serious adverse outcome from this
treatment.
i.I don’t keep my follow-up appointments.
I haveread and understandboth sides of this agreement.My questions have been answered satisfactorily. I
agree to the use of opioids to help control my pain, with treatment to be carried out as described above.
Worker’s signatureDateProvider’s signatureDate
Provider: Keep a signed copy on file. Give a copy to the worker. Send a copy to L&I. You shouldrenew this
agreement yearly.
F252-095-000 Opioid Treatment Agreement 07-2013 INDEX: OPI – Do Not Route
RESET
Worker’s name
Claim number
Safety risks while working under the influence of opioids
Opioids decrease reaction time, cloud judgment, and cause drowsiness and tolerance. Also, it could be
dangerous for you to operate heavy equipment or drive while under the influence of opioids.
Sideeffects of opioids
Some of the following sideeffects may worsen if you mix opioids with other drugs, including alcohol.
•Confusion or other changes
in thinking ability
•Nausea/Vomiting
•Constipation
•Dry mouth
•Low testosterone
•Central sleep apnea
•
Opioid use disorder or
addiction
•Breathing too slowly – overdose
can stop your breathing and lead to
death
•Aggravation of depression
Other risks
Physical dependence– Abruptly stopping use of the drug may cause withdrawal symptoms, which could
include:
•Runny nose
•Abdominal cramping
•Rapid heart rate
•Diarrhea
•Sweating
•Nervousness
•Difficulty sleeping
•Goose bumps
Psychological dependence – It is possible that stopping the drug will cause you to miss or crave it.
Tolerance – You may need more and more drug to get the same effect.
Addiction – Patients may develop addiction based on genetic or other factors.
Problems with pregnancy – If you are pregnant or contemplating pregnancy, discuss with your provider.
Recommendations for managing your medication
•Keep a diary of the pain medications you are taking, the doses, time of day you take them, their
effectiveness and any sideeffects youmay have.
•Take along only the amount of medication you need if you leave home. This lessens the risk of losing all
your medications at the same time.
•It’s important to dispose of your medication properly to avoid harmto others. Here are some disposal
options and special disposal instructions for you to consider when throwing out expired, unwanted, or
unused medicines:
oMedicine Take-Back Programs - Contact your city or county government's household trash and
recyclingservice to see if there is a medicine take-back program in your community.
oDisposal in Household Trash - Mix medicines (do NOT crush tablets or capsules) with an
unpalatable substance such as kitty litter or used coffee grounds; place the mixture in a container
such as a sealed plastic bag; and throw the container in your household trash.
oFlushing of Certain Medicines - Contact the FDA at 1-888-INFO-FDA (1-888-463-6332) to see if
your medication has specific disposal instructions indicating it should be flushed down the sink or
toilet.
F252-095-000 Opioid Treatment Agreement 07-2013 INDEX: OPI – Do Not Route
