Tailoring Monitoring to Risk Level
Monitoring should be adapted to patient need. See “risk assessment and monitoring” for ways to determine low, medium or high risk. Even if a patient does not test as high risk on the standard forms, any aberrancies can move the patient into a higher category.
Recommended Risk Monitoring Schedule
Low risk in first 12 months of treatment
Minimum 6 - up to every prescription
 UDTfrequency may be dictated by regulations for more frequent intervals
 DEA regulations on controlled substance are for 1 month supply and 2 additional refills before face to face visit. Note that monitoring should be more intensive during the first 6 months of opioid therapy.
In 2020 because of the Covid pandemic, the practice of medicine and regulations have changed. Telemedicine visits may substitute for in person visits. Drug testing and pill counts may need to be modified based on the situation of the patient and the local context.
Guidelines vary by state. If no state guidelines, the CDC recommends that you use PDMP:
At start of new prescription When prescribing to new patient, even if evidence of prior use At least yearly, more often if there is high risk
Urine drug testing (See About Urine Drug Testing, Interpreting Urine Drug Tests) Every 6 months for low risk patients More often for higher risk patients Every visit for high risk patients
If there is suspicion of misuse, conduct in between visits For high risk patients at every visit
Length of Interval of Prescription
Giving 28-day refills assures that the prescriber will be available on the day that the prescription is due, assuming a regular clinical schedule For high risk patients, decreasing the length of the interval between prescriptions provides an opportunity for increased monitoring. The decreased prescription may help patients develop control of medication use and provide them with the support they need to maintain control of their opioid medication.For very high risk patients even as little as 3 days prescription may be useful. Once a patient becomes stable, they can move into the moderate category
Minimum Primary Care Clinician Visits Per Year
Patients receiving controlled substances need a face-to-face encounterevery 3 months where the pain and opioids are addressed, per DEA regulations High risk patients should be seen more often for monitoring. Expert opinion suggests a minimum of 6 times per year Sources:
Christo PJ et al. Urine drug testing in chronic pain. Pain Physician 2011: 14: 123 - 143.
Heit HA and Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage 2004; 27: 260 - 267.
Manchikanti L et al. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Pain Physician 2006.
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.
Peppin JF et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Medicine 2012; 13: 886 - 896.
Perrone J, Nelson LS. Medication reconciliation for controlled substances–an “ideal”prescription-drug monitoring program. N Engl J Med 2012; 366: 25: 2341 - 2343.
Pesce Aet al. Illicit drug use in the pain patient population decreases with continued drug testing. Pain Physician 2011.