Risk stratification	Recommended monitoring
Standard risk Baseline for everyone who receives chronic opioid medication from our practice	Baseline for everyone: Quarterly office visits Contract yearly UDS every 6 months PMP with every prescription If new to practice, consent to obtain medical records from past provider
Moderate risk Request for increase in pain meds Nonadherence to adjunctive therapy (PT, exercise, pain/rehabilitation medicine appointments) One lost or stolen script/damaged pills Personal history of substance abuse Daily dose greater than or equal to 90 mg morphine equivalents	In addition to baseline: UDS every 4 months Other suggestions: Discussion regarding pain management goals and review of opioid agreement Consider referral to Pain Clinic or Rehabilitation Medicine
High risk Nonadherence to monitoring guidelines—refusal to leave urine, not meeting minimal office visit requirements (canceling appointments) Multiple lost or stolen scripts/damaged pills Taking medication differently than prescribed resulting in request for another prescription early Multiple ED visits Concomitant use of benzodiazepines UDS negative for prescribed medications UDS positive for “other” substances	In addition to baseline: Monthly or every other month office visits UDS every 3 months—consider true random testing Other suggestions: Discussion regarding pain management goals and review of opioid agreement Consider 14-day prescription schedule Loss of privilege to pick up scripts early High consideration to an individualized treatment plan, may include: Random UDS or pill checks UDS and PMP checks with every prescription Weekly or q 14 day prescription schedule; possibility of lengthening schedule thereafter Adjunctive therapies including pain clinic, rehabilitation medicine, social work, or drug counseling referrals Possible termination
Termination PMP confirms receipt of narcotics from multiple non-ED providers Confirmed illegal activity—selling/diverting pills, forging scripts Overdose on opioid or illegal substances Noncompliant to individualized treatment plan	Termination of opioid prescribing/1 month taper Substance abuse program Weaning protocol

Abbreviations: ED, emergency department; PT, physical therapy; PMP, prescription monitoring program; UDS, urine drug screen.