Each person’s pathway to opioid addiction is as unique as their pain diagnosis. The following questionnaire is an opportunity for you to better determine what your relationship is between addiction and the use of opioid medications. Consider sharing and discussing your answers with your healthcare provider as a step toward improved treatment and living a healthier lifestyle. 1. Have you ever reported your pain as more severe than it really was in order to obtain more or stronger pain medicines? If you have done this, what did you tell yourself to make it OK to misreport this information to your doctor and/or nurse? For each of the following locations of care, how many times have you done this? Regular clinic/provider Pain doctor Emergency room Immediate/urgent care 2. Have you ever obtained prescriptions for painkillers in any of the following circumstances? From more than one doctor at the same time From an Internet pharmacy When traveling to Mexico or Canada Did you tell anyone that you were doing this? If you didn't, how did you keep them from finding out? 3. Have you ever gone to more than one pharmacy to be sure the prescription would be filled? If so, how many pharmacies did you go to? 4. In any of the above situations, to what length did you go to keep this a secret? 5. Have you paid cash for your painkillers because it was too soon for your insurance company to approve a refill of the medication? 6. How often have you run out of medication too early? 7. How many times have you paid cash for your pills in the last 6 months? 8. Have you ever taken painkillers that were prescribed to someone else? Who did they belong to? Did you steal them or buy them? What did you tell yourself to make it OK to do this? 9. Have you ever injured yourself in order to get painkillers? What did you do? How were you impacted by your actions? How were others impacted? 10. Have you ever had a medical procedure that you didn't really need in order to have access to painkillers? What did you tell yourself to rationalize this behavior? Did you have complications from these procedures? 11. Has taking more opioid pain medicine over time led to: Improved pain control of your primary pain diagnosis? Improved pain control of other diagnoses? Worse pain control over your primary pain diagnosis? Worse pain control related to other diagnoses? 12. Has taking pain medication caused symptoms to occur that were not there before you started taking pain medication? If yes, what symptoms? Pain, anxiety, depression, sleep problems, digestive problems, constipation, other symptoms? 13. Have you ever taken pain medication to feel emotional relief from pain? 14. Have you taken your medication, not as prescribed, to get high? If so, when was the first time you did this? How often have you done this in the last 6 months? 15. Have you ever taken too much of your pain medicine requiring you to seek medical help? When did this happen? What were the consequences (including medical care)? 16. Has a loved one or friend expressed concern about you and pain medication? When was the first time this happened? What did they say? How did that make you feel? 17. Are you able to think about living your life without opioids? What are your feelings about this? 18. Do you feel that you deserve to take pain medicines? What are your feelings about this? 19. In what other ways have prescription painkillers complicated your life?