Proper medication monitoring ensures that patients receive the proper and effective dose of pain medication, take their medication as directed, and gain positive outcomes.  Monitoring also plays an important role in helping physicians identify potential interactions with other legal prescription medications and over the counter remedies the patient may be taking.  Additionally, monitoring is an important and unique element of the fight to reduce prescription drug diversion and abuse.  The following independent reports, articles and guidelines demonstrate the value of medication monitoring as part of the treatment of patients on chronic opioid therapy.

Author & Organization Document Summary of Recommendation(s)
Centers for Disease Control and Prevention (CDC) Vital Signs™ Prescription Painkiller Overdoses in the US.  November 2011. The CDC recommends “Using patient-provider agreements combined with urine drug tests for people using prescription painkillers long term.”
Chou, R. et al; The American Pain Society and the American Academy of Pain Medicine Opioid Treatment Guidelines. The Journal of Pain.   2009;Feb;10(2):113-130 In patients on chronic opioid therapy (COT) who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care.

In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care.

Government Accountability Office (GAO) Medicare Part D.  Instances of   Questionable Access to Prescription Drugs.    GAO-11-699.  September 2011. The GAO discussed the growing rate of abuse, misuse and diversion of opioid medications in the Medicare population.
Institute for Clinical Systems Improvement (ICSI) Guideline for the assessment and management of chronic pain. November   2011 “Random drug screens are one tool to monitor compliance with the opioid regimen. Random urine drug screens are used: (1) to check for diversion, seeking evidence the patient is taking the medication being prescribed, (2) to check for drugs of abuse, and (3) to test for the presence of the prescribed drug. Any evidence of street drug use indicates non-compliance with the opioid contract.”
King L, et al.; American College of Physicians Physicians’ Information and   Education Resource (PIER). January 17, 2012 Recommendations for treating chronic nonmalignant pain with opioids includes the following statement: “Monitor carefully for signs of opioid abuse using comprehensive clinical evaluation and urine drug testing.”
Management of Opioid Therapy for Chronic Pain Working Group; Department of Veteran Affairs and Department of Defense VA/DoD.  Clinical guideline for   the management of opioid therapy for chronic pain. Version 2.0 2010. A urine drug test (UDT) (also referred to as urine drug screen (UDS)) should be used to screen for the presence of illegal drugs, unreported prescribed medication, or unreported alcohol use prior to starting therapy. UDT or other laboratory tests should be part of a comprehensive patient assessment.
National Institutes of Health (NIH) Principles of drug addiction treatment: A research-based guide. US   Department of Health and Human Services, National Institute of Drug Abuse.   1999. Drug use during treatment must be monitored continuously. Knowing their drug use is being monitored can be a compliance incentive for patients. Monitoring also provides an early indication of a return to drug use. The physician can use this information to potentially adjust a patient’s treatment plan.
Peppin, J., Passik, S., et al. Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain. Pain Medicine, 13 (7), 886-896. “Clinicians need to recognize that all patients have a degree of risk for misuse of opioids and that monitoring is necessary to maintain patient safety, structure care with greater objectivity, and guide ongoing treatment decisions,”

“Given the difficulty in identifying drug use behaviors with subjective data, all patients who are prescribed a short- or long-acting opioid for long-term pain management (defined as >3 months by the recommendations panel) should be tested.”

“Patients at low risk of misuse may be periodically eligible for monitoring at each visit, with a minimum of one test conducted every 6 months.”

“Patients at medium to high risk may be periodically eligible for monitoring at each visit, with a minimum of one test conducted every 3 months.”

Trescot, A. et al.; American Society of Interventional Pain Physicians’ (ASIPP) Opioids in the Management of Chronic Non-Cancer Pain: An Update of   American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines.   Pain Physician. 2008; 11:S5-S62 Urine drug testing should be used in the management of chronic pain with an appropriate level of understanding to diagnose substance abuse or appropriate intake of drugs. Urine drug testing should be random.
Trescott, C. et al Group Health’s Initiative To Avert Opioid Misuse And Overdose Among Patients With Chronic Noncancer Pain Health Affairs, 30, no.8 (2011):1420-1424 Group Health, a Seattle-based nonprofit health care system, implemented a large initiative to make opioid prescribing safer. As part of the initiative, periodic urine drug screening was recommended for patients on higher-dose regimens or with significant risk factors for opioid abuse. An initial evaluation of the Group Health initiative is under way. It will first examine issues such as the timeliness of monitoring visits, the use of urine drug screening, and the extent to which patients received supplies of opioids from multiple prescribers. The evaluation will then assess trends in the rates of adverse events.
White House 2011 and 2010 National Drug Control Strategies Preventing the misuse and diversion of prescription drugs while ensuring the availability of these important medications for those who have a medical need for them, requires a multi-pronged approach that includes prescriber and patient education, monitoring systems, disposal, and enforcement strategies.
White House Epidemic: responding to America’s prescription drug abuse crisis. 2011. This Prescription Drug Abuse Prevention Plan expands upon the Administration’s National Drug Control Strategy and includes action in four major areas to reduce prescription drug abuse: education, monitoring, proper disposal, and enforcement. The Plan also encourages an increase in the use of Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs to help healthcare providers identify and prevent prescription drug abuse problems in primary healthcare settings.