This document is a referral form for a pain clinic recommending the patient be referred for addiction consultation. It provides information on the patient's diagnosis, current morphine equivalent dose, whether CDC guidelines were discussed, number of opioid prescribers in the prior year, results of recent drug screening, fibromyalgia and pain catastrophizing scores, and signatures of the patient and referring provider acknowledging review of the reason for referral.

1. I am recommending that my patient _____________________________________________
Be referred to the pain clinic for the following reason:
❏ Taper and/or convert to buprenorphine
❏ Positive screen for fibromyalgia, discontinue opioid use
❏ Addiction consultation
❏ Other:_________________________________________________________________
Diagnosis:____________________________________________________________________
Morphine Equivalent Dose:______________________________________________________
If MED < 90 without aberrancy, consider not referring.
Were the CDC guidelines discussed with the patient? Yes No
If MED > 90 was the need for a taper discussed? Yes No N/A
Number of opioid prescribers in the prior year:_______________________________________
Is the patient co-prescribed benzodiazepines or SOMA? Yes No
Most recent UDS date:__________________________________________________________
UDS Result: Consistent Inconsistent
Fibromyalgia Survey Questionnaire Score:__________________________________________
If > 13 consider FMS as the primary pain diagnosis.
Pain Catastrophizing Score:______________________________________________________
If > 30 consider a referral to behavioral health.
My primary care provider and I have discussed and reviewed the reason for my referral to the
pain clinic.
____________________________________________________________________________
Patient Signature Date
____________________________________________________________________________
Provider Signature Date