Safe Opioid Monitoring Principles

Best Practices in Safe Ppioid Monitoring May Include

  • Understand risks of opioid dose escalation
  • Recognize the risks of combining opioids with other central nervous system depressants such as benzodiazepines
  • Consider using a validated questionnaire to assess function, pain severity and interference with enjoyment of life as well as opioid misuse risk

Assess the following at each visit (“8 A’s”)

  • Analgesia (is it helping reduce pain?
  • Adverse effects (side effects?)
  • Function including ability to perform Activities of daily living (ADLs) such as errands, home housework, attending social engagements or appointments, returning to work, etc.
  • Presence of Aberrant drug-related behaviors
  • Prescription monitoring program data, urine drug monitoring, assess for cravings
  • Affect (how is mood?)
  • Use of Adjuvants (what other non-opioid medications and strategies?)
  • Adherence to therapy (taking as prescribed?)
  • Access to multimodal treatment


AAPM & APS. The use of opioids for the treatment of chronic pain. A consensus statement. 1996.

Risks of Developing an Opioid Use Disorder when Prescribed an Opioid for Pain

  • Studies including over 310,000 patients prescribed opioids showed fewer than 5% of patients develop iatrogenic dependence or misuse when prescribed opioids for pain.1
  • A different study of over 1 million patients showed the rate of opioid misuse/addiction after surgery at less that 1%, with slightly higher rates for 15-24 year olds.2


  1. Higgins C, Smith BH, Matthews K.  Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis.  Br J Anaesth. 2018;120:1335-44.
  2. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018;360:j5790.

Should We Limit Opioid Use to Less than 90-100mg Morphine Equivalents (MME)?

  • Defining a dose ceiling is controversial.  There is no clear answer to this question that applies to all patients – and an individualized plan is necessary.  Consensus statements, such as from the Centers for Disease Control (CDC) in 2016, do recommend setting limitations to daily opioid dosing.1
  • In a study of 2 million patients prescribed opioids, 0.02% died of an overdose2
  • There was a dose-dependent effect seen above 200 mg/day MME but not at 100 mg/day MME or 120 mg/day
  • Benzodiazepines in particular increase the risk of opioid overdose 10-fold
  • Toxicology results indicate however, that 25% of overdose deaths involve more than one opioid, and 66% of overdoses are likely linked to illicit opioids3-4
  • In addition to the risks and side effects associated with chronic high dose opioid therapy, higher doses of opioids have been suggested to lead to increased pain sensitivity, or hyperalgesia.


  1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recommendations and Reports.18;65(1):1-49.  
  2. Dasgupta N, Funk MJ, Proescholdbell S, et al. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016 Jan;17(1):85-98
  3. Hedegaard H, Warner M, Miniño AM. Drug Overdose Deaths in the United States, 1999–2016.  NCHS Data Brief No. 294.
  4. Rudd RA, Seth P, David F, Scholl L. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445-1452

Possible Measures to Monitor and Address Adherence to Opioid Medications

  • Implement and periodically review with the patient a written controlled substance treatment agreement.
  • Perform periodic urine drug monitoring (frequency based on patient risk factors, but at least every 6-12 months to confirm the presence of the prescribed medication and monitor for other substances)
  • Provide in-person patient consultations to monitor side effects and safe use (visit frequency based on patient risk), at least once very 3-4 months.
  • Perform pill/patch counts.
  • Review the state prescription monitoring program database (to assess appropriate refill dates, numbers of prescriptions/prescribers, other controlled substance prescriptions, etc.) and counsel the patient on the results to reinforce adherence.





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