Continuing Opioids

Tailoring Monitoring to Risk Level

monitoring tools

See below for more details


Monitoring Tools:


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 very high risk patients.


State prescription monitoring program (PMP) (See “Using the PMP Effectively“)

  • 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.


Pill counts (See “Pill Counts“)

  • If there is suspicion of misuse, conduct 1 week before new prescription due.
  • Some at every visit.


                                    Recommended Risk Monitoring Schedule 

Risk Level
Urine Drug Tests
(per Year)
Prescription Drug Monitoring Plan
(per Year)
Pill Counts
(per Year)
Minimum Primary Care Physician Visits
(per Year)*
Low risk in first 12 months of treatment 1-31-314
HighMin 6 - up to every prescription43+6
UDT frequency may be dictated by regulations for more frequent intervalsPDMP frequency 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

Also see: “Determination of Risk



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Heit HA and Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage 2004;27:260-267.

Katz NP et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003.

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 A et al. Illicit drug use in the pain patient population decreases with continued drug testing. Pain Physician 2011.