This patient's long-term opioid therapy should be monitored with surveillance of a prescription monitoring program, if available. Prescription monitoring programs are state-run systems that gather information on controlled substance prescriptions from pharmacies and prescribers, allowing prescribers to view a patient's controlled substance history and to monitor controlled substance use. This information is helpful in documenting adherence and for early detection of possible abuse.

Although there is little to no evidence supporting the use of long-term opioid therapy for chronic noncancer pain, there are substantial documented risks, even in patients who are compliant and whose medication is prescribed within recommended guidelines. As such, the decision to treat patients with long-term opioid therapy should be made with great care. Although the evidence that shows improved outcomes with various risk mitigation strategies is weak, most guidelines strongly recommend employing a risk assessment tool (such as the DIRE [Diagnosis, Intractability, Risk, and Efficacy] score), baseline urine drug screening, and written treatment agreements. Guidelines also agree that adherence monitoring in the form of regular surveillance of prescription monitoring programs should be performed to reduce prescription drug abuse. With continuous adherence monitoring, opioid therapy can be maintained in appropriate populations with improvement in physical functional status and minimal adverse effects.

Documentation of opioid side effects (cognitive impairment, sedation, constipation, falls), absence of aberrant opioid behavior (lost prescriptions, early refill requests, multiple concurrent opioid providers or “doctor shopping,” consistently missed appointments, or erratic follow-up), and the patient's enduring functional improvement is recommended at every visit in order to justify the ongoing benefit of continued opioid therapy.

Experts recommend frequent and regularly scheduled office visits indefinitely as long as the patient remains on opioid therapy. Follow-up functional assessment twice yearly in a patient being started on long-term opioid therapy would not be adequate to monitor medication adherence, appropriateness of dosing, or potential side effects. Converting to as-needed follow-up after 3 months also would not be appropriate.

Guidelines recommend baseline and periodic urine drug testing to assess adherence, but there is no recommendation that it be performed at every visit.