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Adherence Monitoring

Adherence monitoring is an integral part of treating a chronic pain patient. There are several approaches for monitoring a chronic pain patient's adherence to a drug regimen. Simply asking a patient how many pills he or she has left is a traditional, albeit imperfect, method of adherence monitoring. Random pill counts to assess overuse or diversion is a better objective measure of adherence and should be a stipulation in the controlled substance agreement. Screening tools, such as detailed questionnaires, that are usually employed at the beginning of a treatment process can be used again at some point during treatment.

Prescribing physicians can also observe behavioral and biological indicators to determine a patient’s adherence to treatment. According to Manchikanti, et al., “there is considerable research” regarding certain behaviors of chronic pain patients and whether these behaviors indicate drug misuse. The table below provides some examples.

Behaviors Predictive of Addiction

  • Selling prescription drugs
  • Prescription forgery
  • Stealing or “borrowing” drugs from others.
  • Injecting oral formulations
  • Obtaining prescription drugs from nonmedical sources.
  • Concurrent abuse of alcohol or illicit drugs
  • Multiple dose escalation or other noncompliance with therapy despite warnings
  • Multiple episodes of prescription “loss”
  • Repeatedly seeking prescriptions from other clinicians or from emergency rooms without informing prescriber or after warnings to desist
  • Evidence of deterioration in the ability to function at work, in the family, or socially that appears to be related to drug use
  • Repeated resistance to changes in therapy despite clear evidence of adverse physical or psychological effects from the drug

Behaviors Not Predictive of Addiction

  • Aggressive complaining about the need for more drugs
  • Drug hoarding during periods of reduced symptoms
  • Requesting specific drugs
  • Acquiring similar drugs from other medical sources
  • Unsanctioned dose escalation or other noncompliance with therapy on one or two occasions
  • Unapproved use of the drug to treat another symptom
  • Reporting psychic effects not intended by the clinician
  • Resistance to a change in therapy associated with “tolerable” adverse effects with expressions of anxiety related to the return of severe symptoms

Source: Manchikanti, et al., 2008.

Checking Prescription Monitoring Programs

It is important for the prescriber to balance optimal pain control while realizing potential for diversion or opioid misuse. Prescription Drug Monitoring Programs (PDMPs) provide a useful tool to assist the clinician with determining appropriate use of controlled substance medications

Prescriber Recommendations for use of Prescription Monitoring Program Data:

  • Request a PDMP report as a normal process of accepting a new patient. This information can assist the provider with determining any potential drug-drug interactions with any potential prescribed therapy.
  • Prescribers should access PDMP patient data prior to appointment to facilitate meaningful interactions. Reports should be requested with every new patient encounter AND randomly for patients receiving chronic controlled substance prescriptions as part of a periodic review. Data can help prescribers to:
    • Check for addiction or undertreated pain
    • Check for misuse, multiple prescribers
    • Check for drug interactions or other harm
    • Use reports for compliance with pain agreements
  • Register with state PDMP: not only for patient history reports but also for prescriber history reports. Prescriber history reports can assist you with determining fraudulent prescription activity. Self-audits should be conducted monthly.
  • Use delegate accounts where authorized. Delegates can help prescribers reduce time conducting queries. Check with your state to see if delegates are allowed. Recommend a maximum two delegate accounts per prescriber. Remember that the prescriber is ultimately responsible for reports requested by the delegates.
  • Document results and clinical decision making in the patient record. Check with your Area Pharmacy Consultant for your regional recommendation.
  • If you detect a patient with possible aberrant behavior, it is important to take appropriate action


Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 58–61

Manchikanti, MD, Laxmaiah, et al. “Monitoring Opioid Adherence in Chronic Pain Patients: Tools, Techniques, and Utility.” Pain Physician 11 (2008): S155–S180.