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.
Monitoring Tools
UDT's
State PDMP
Pill Counts
Recommended Risk Monitoring Schedule
State PDMP
State prescription drug monitoring program (PDMP) (See Using the PDMP Effectively)
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
UDTs
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
Pill Counts
Pill counts (See Pill Counts Strategies)
  • If there is suspicion of misuse, conduct in between visits
  • For high risk patients at every visit
Length of Interval of Prescription
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.