Appropriate Documentation of Opioid Prescriptions


Opioid deaths are on the rise in the United States. According to a recent Medicare and Medicaid Research Review report, the rate of overdose deaths in the U.S. has increased by 137 percent since 2000, with a 200 percent increase in opioid-related overdose deaths. Many of those deaths can be traced back to prescription opioid abuse.

While physicians are acutely aware of the drawbacks and dangers of opioid prescribing, use of opioids continues to be a valid approach to chronic pain management. The primary issues for physicians are determining the needs of the patient, avoiding overuse of opioids as the only method of pain management, implementing alternative treatments for pain relief and identifying patients who are "doctor shoppers" to support their addiction.

Today, there are more resources available for physicians to combat "doctor shoppers" and opioid over-prescribing, with electronic health records and patient databases taking over the medical industry. For many physicians, it's a matter of educating themselves on proper opioid prescription documentation and the resources available to help.

Opioid Prescribing Guidelines

In response to the growing opioid epidemic across the United States, prescribing guidelines have been developed at both the state and federal perspective. The CDC and most individual states have released prescribing guidelines for opioid management of chronic pain. The guidelines help providers make safe and competent opioid prescribing decisions in primary care settings, recommending certain patient-centered practices before and during an opioid-based treatment.


The primary foundation of these opioid prescribing guidelines generally includes the following:

Determining When to Use Opioids: 

The decision to use opioids instead of alternative treatment plans must follow a thorough process of treatment selection. First, a physician should use non-pharmacologic therapies like exercise or cognitive behavioral therapy before seeking pharmacologic therapies for chronic pain. Physicians should also explore the possibilities of non-opioid pharmacologic therapies like anti-inflammatories before resorting to opioids.

When the physician determines that an opioid must be used, the guidelines recommend the opioid treatment is combined with an additional non-pharmacologic or non-opioid pharmacologic therapy when appropriate. Opioid-based treatments should never be the first resort and must be accompanied by the establishment of concrete treatment goals and a discussion of the risks of opioid therapy with the patient in question.

Managing Opioid Treatments: 

Every aspect of an opioid treatment plan must be managed by the prescribing doctor to avoid misuse or abuse by the patient. At the same time, the physician should ensure that the treatment is effective for the patient's chronic pain. This management must involve a process of selecting the appropriate opioid and dosage for the treatment, determining the duration of the treatment and following up with the patient to track their progress.

The CDC recommends prescribing the lowest possible effective dosage using immediate-release opioids — this minimizes the potential for abuse or overdosing. This focus also involves the process of following up with the patient and deciding when to discontinue an opioid treatment.

The physician also needs to be mindful of the total Morphine Equivalent Dose (MED) for all patients receiving opioids. Should the MED prescribed for the patient be greater than 100-120 MED daily, the physician needs to consider transferring care to a pain management specialist.

Assessing and Addressing Risk: 

The primary purpose of regular follow-up meetings with patients is to ensure the patient is using their opioids in an appropriate manner and that the opioids are improving their pain and function. This monitoring may include urine drug testing, PDMP reviews or simple discussions with the patient. In some cases, the benefits of using opioids may not outweigh the potential harm, in which case the physician must take appropriate steps for the sake of the patient. If this is the case, the physician can work with the patient to taper, reduce or discontinue their opioid usage.

Physicians should monitor patients on a regular basis to ensure their opioids are improving pain and function without causing harm. If benefits do not outweigh harms, optimize other therapies and work with patients to taper or reduce dosage and discontinue, if needed. If the harm to the patient is extensive and the patient has started to abuse opioids, the physician must also play a role in arranging treatment for the patient.

The Physician's Role in Opioid Prescribing

Physicians are the last line of defense against opioid over-prescribing. While the number of resources available to physicians today has expanded, too few physicians make appropriate use of them or have the experience and skills necessary to judge a patient's honesty. For a doctor prescribing opioids, the consequences of improper documentation of a prescription or misjudgment of a patient can be severe, resulting in a patient's death and disciplinary action by the physician's licensing board.

To prevent potential patient abuse, physicians must make use of the tools and procedures at their disposal, including:

  • Prescription Drug Monitoring Program (PDMP) Database Access: The PDMP database is a critical part of preventing over-prescribing and combating "doctor shoppers." These databases allow physicians to access patient information, which includes prescription history: what prescriptions the patient is filling and from whom the patient has received the prescription. This is an important tool for screening new patients, especially those who exhibit red flags during their initial meeting.
  • Initial Screening: Patients presenting with acute or chronic pain complaints need to be initially assessed to ensure the appropriateness of treatment. Such initial screening tools include urine drug screening tests, self-assessment surveys, review of past medical history and current treatment.
  • Thorough Examinations: Physical examinations can also be of use to physicians thinking of prescribing opioids. Inconsistencies between patient statements and test results can provide vital information about the patient's behavior, state of mind and habits.
  • Comprehensive Documentation: Documentation is one of the most important tools in a physician's arsenal when it comes to preventing opioid abuse. Tracking patient examinations, follow-ups, prescriptions and refills is an important part of identifying problematic behavior. Notations of calls made by the patient requesting early refills, lost prescriptions or pills can be extremely valuable when assessing potentials for abuse or diversion issues. Documentation can also be used by physicians to defend prescription decisions in the event a medical board questions their prescribing habits.

Documenting Opioid Prescriptions

Electronic health records (EHRs) have made patient medical documentation more detailed and accessible than ever before. Despite these advances, medical documentation often involves little more than a few checked boxes and notes. While this kind of documentation is sufficient for minor checkups, for opioid prescriptions the standard of care should be much more.


Doctors should document their reasoning from beginning to end for providing an opioid prescription, especially if the treatment resulted in opioid abuse. Many doctors are unaware of this or otherwise lack the experience necessary to document their opioid prescriptions in a way that's deemed acceptable.

Some of the documentation expected includes the following:

Initial Visit: 

A patient's first visit is a major factor in the opioid prescription process, especially when it comes to avoiding doctor shoppers. Physicians can later refer to this initial visit if a patient claims long-term chronic pain or makes claims about previous prescriptions. In any case, documentation of an initial visit should include information about a patient's history, including the history of their chronic pain, the type and intensity of the pain, the results of previous diagnostic studies and specific details about previous treatments, including any medications taken.

Any information collected during this initial visit should be backed up with records from a patient database, so having the patient sign a release form and provide contact information for their prior relevant physicians is crucial.

Baseline Screenings: 

If an opioid is chosen for a patient's treatment plan, the patient should go through a basic screening process. In most cases, this will include a discussion with the physician, where he or she asks general questions to determine the patient's state of mind and pinpoint any inconsistencies. It will also include an initial urine analysis to check for the presence of drugs in the system as well as a medical history check for previous abuses or aberrant behavior. Any results, especially red flags, should be documented.

PDMP Information: 

Most states now have an operational Prescription Drug Monitoring Program or legislation authorizing the development of such a database. The PDMP provides the physician with a list of all controlled substances filled by a patient and who wrote the prescription. In many cases, physicians can register with state PDMPs in bordering states should their patient population cross state boundaries. Any physician planning to prescribe opioids to a patient must check the list to see if the patient is getting opioids from another source already. The results of this check should be documented, whether they are positive or negative.

Treatment Plan and Goals: 

After the initial assessment and screening, documenting the treatment plan and the goals for the treatment should be the next step the physician takes. These plans and goals should be discussed with the patient and should be as quantifiable as possible so that progress can be documented in follow-up visits.

Follow-Up Visits: 

Physicians should also document follow-up visits, addressing treatment goals and detailing the progress the patient has made on the treatment plan, if and how treatment goals have been met and how the treatment is progressing overall. The physician should also document any red flags that come up during their visit with the patient.


In short, physicians must document every interaction with a patient taking opioids in a thorough manner. When in doubt, always document anything having to do with the following topics, also known as the "5A's":

  • Analgesia: The patient's pain levels are a simple way to document chronic pain, measured on a scale of 1 to 10. Inconsistent pain levels or sudden changes in pain levels should be documented.
  • Activities: Inclusion of a functional assessment of the patient's pain is an effective tool. For example, asking the patient how the pain they are experiencing is affecting their abilities to work, do activities of daily living, etc. is a more objective measurement of pain control than a self-reported pain scale. Specific activities detailed in increments of distance or time and notes regarding difficulty in accomplished daily tasks are ideal for documentation of patient progress. Physicians must note any significant changes in activity level.
  • Adverse Effects: Problems with the medication, such as constipation or behavioral changes, should be documented.
  • Aberrant Drug-Related Behaviors: Any changes in refill behaviors should be monitored, as should drug tests that come back positive for controlled substances the patient has not mentioned. If any aberrant behaviors come up, they must be addressed by the physician as soon as possible. Physicians should track any notable changes in behavior or treatment for this reason.
  • Affect: The patient's mood should be monitored because it may affect patient behavior. Depression and anxiety both exacerbate pain in patients and may lead to opioid abuse. Chronic depression and anxiety may need to be addressed by the physician to help the treatment move along as planned. Both the mood of the patient and any psychotherapy they pursue must be noted.

Benefits of Opioid Prescription Education Programs

Proper documentation is a difficult skill for physicians to learn, but is essential to avoid over-prescribing and potential reprimands. To this end, there are resources available for physicians wishing to learn more.

LifeGuard provides a nationally-recognized educational program used by physicians to improve and advance their education in the prescribing of opioids and controlled substances. The Controlled Substance and Opioid Prescribing Educational Program features a curriculum designed to provide education on proper opioid documentation and management for doctors. Some of the key features of LifeGuard include:

  • Comprehensive Material: LifeGuard covers a wide variety of topics, including information on controlled substances. This complex subject is covered in extreme detail to provide physicians with didactic and practical information on the latest prescription and documentation guidelines so physicians can effectively implement them.
  • Practical Application: LifeGuard combines lecture, discussion and experiential practice to help solidify physician knowledge and arm them with the practical skills they need to use what they have learned. The practical aspects of the program include standardized patient practice sessions, observed preceptorships and shadowing experiences.

Learn More About Lifeguard

Supported by the Foundation of the Pennsylvania Medical Society, the LifeGuard program is the result of the society's annual Board of Trustee's retreat. The Society, an association consisting of physicians across Pennsylvania, has dedicated itself to serving the needs of patients and medical professionals since 1848.

With LifeGuard, the Foundation of the Pennsylvania Medical Society sought to fulfill the needs of physicians seeking continuing educational resources. Since its establishment, LifeGuard has grown to become a nationally-recognized program, celebrated for its quality assessment techniques, personalization and support.

For more information about LifeGuard's Controlled Substance and Opioid Prescribing Educational Program, email or call (717) 909-2590.