Potential Risks, adverse reactions, complications, and medication interactions associated with opioids, including death (but are not limited to the following): allergic reactions, slowing of breathing rate, slowing of reflexes or reaction time, sleepiness, dizziness and/or confusion, impaired judgment and inability to operate machines or drive motor vehicles, nausea, vomiting and/or constipation, itching, physical dependence or tolerance to pain relieving properties of the medication, addiction, changes in sexual function, changes in hormonal levels.
• If a benzodiazepine is taken with on opiate there is an increased chance of slowing of the breathing rate, sleepiness, dizziness, confusion, impaired judgment.
• Use of opiates poses a special risk to women who are pregnant or who may become pregnant. If I plan on becoming pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetrician and this office to inform them.
 The following alternatives to prescribed opioid have been explained to me and I have freely consented to taking opioid medication:
• Acetaminophen
• Nonsteroidal Anti-Inflammatory Drugs (NSAID’s)
• Corticosteroids
• Serotonin and Norepinephrine Reuptake Inhibitors
• Neuro stimulators
• Anticonvulsants
• Physical Therapy
• Massage, Acupuncture, Chiropractic Care
• Injections (Nerve, trigger point, Radiofrequency or epidural injections)
• Exercise
Monitoring for effectiveness will occur with this medication, if used for more than 30 calendar days, as follows:
• Frequency of office visits
• Frequency of substance abuse assessment
The undersigned attests that s/he has been informed and understands the risks, benefits and alternatives of opioid pain medications and their alternatives. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. By signing this form voluntarily, I give my consent for the treatment of my pain with opioid pain medicines.