Opioid Therapy Management Note

Date: [Date]

Patient: [Patient name or identifier]

Provider: [Provider name, credentials]

Visit Type: [new / established]; [in-person / telehealth]

Purpose: [LTOT follow-up / opioid reassessment / taper planning / transfer of prescribing / other]

Opioid Therapy Snapshot

• Indication: [Specific pain diagnosis with laterality if applicable]
• Current opioid regimen: [Drug, formulation, strength, dose, frequency; start date if recent change] — Total daily MME: [MME value or range if PRN] (Include calculation basis; use range for PRN dosing.)
• Functional status and goals: [Validated measure such as PEG score and/or concrete activity targets] — Baseline → Current: [Baseline functional status] → [Current functional status]
• Co-prescribed CNS depressants and overdose risk factors: [Benzodiazepines, gabapentinoids, muscle relaxants, Z-drugs, alcohol use, sleep apnea, COPD, renal/hepatic impairment, age >65, prior overdose, etc.]
• PDMP review: [Date/time reviewed] | [Jurisdictions queried] | Findings: [Summary; note any red flags] (If not done: document reason and plan with timing.)
• UDT status: [Most recent date] | [Screen / Confirmatory] | Interpretation: [Expected / Unexpected—explain briefly] (If unexpected, note confirmatory testing plan. If not done: document reason and plan with timing.)
• Risk mitigation: Naloxone: [Offered / Prescribed / Declined / Not done—reason and plan] | Opioid treatment agreement: [On file with date / Due—plan to complete]
• Current decision point: [continue / adjust dose / taper / rotate / transition to buprenorphine / discontinue / hold pending evaluation]

Subjective

[Interval history since last visit covering pain pattern, functional status, opioid effectiveness framed in functional terms, adverse effects, medication adherence, and patient-reported substance use if relevant] (For stable patients, keep concise but address function, benefit, adverse effects, and adherence.)

Objective

• Vitals: [BP, HR, RR, SpO2 as relevant] (Prioritize respiratory status in high-risk patients or with dose changes.)
• Focused exam: [Sedation level, respiratory effort, gait/balance, affect/mental status, pertinent musculoskeletal/neurologic findings] (If limited or deferred, document reason.)
• PDMP/UDT clarifications: [Explanation of unexpected results, confirmatory testing plan, discussion of discrepancies with patient, contacts with other prescribers or pharmacies] (Only if additional detail beyond Snapshot is needed.)

Assessment

[Synthesis confirming ongoing indication, benefit-versus-harm determination linking functional progress to adverse effects and safety risks, clinical risk stratification as low/moderate/high with supporting factors, and adherence impression based on alignment between patient report and objective monitoring data] (Clearly state why continuing, adjusting, tapering, or discontinuing is warranted. Avoid inferring absence of misuse from patient report alone; qualify as "no concerns identified today based on available data" when appropriate.)

Plan

• Opioid management decision: [continue / adjust dose / taper / rotate / transition to buprenorphine / discontinue / hold] — Rationale: [Link to function and safety data]
• Opioid orders: [Drug, formulation, strength, dose, frequency, quantity, days' supply] — Updated MME: [Value] (Include only if prescribing.)
• Non-opioid therapies: [Adjunct medications, interventional options, PT/exercise, behavioral pain therapies] (Include only if specifically planned.)
• Monitoring plan: Next PDMP: [Timing] | Next UDT: [Date and frequency based on risk level] | [Pill counts, pharmacy lock-in, or visit frequency if applicable]
• Risk mitigation: Naloxone: [Prescribed today / On hand / Declined—counseled] | Safety counseling: [Overdose recognition, storage, disposal, driving/machinery]
• Taper or transition: Rationale: [Reason] | Shared decision-making: [Summary] | Schedule: [Dose reduction plan] | Withdrawal management: [Supportive strategies] | Safety counseling: [Tolerance decreases during taper; overdose risk with return to prior doses] (Include only if taper initiated or planned.)
• Aberrant behaviors or adherence concerns: [Objective description of behaviors] | Safety actions: [Confirmatory testing, increased monitoring, limited quantities, holds] | Expectations communicated: [Specific expectations] (Include only if concerns identified.)
• Coordination: [Communication with other prescribers, pharmacy, care team] (Include only if applicable.)
• Follow-up: [Interval and mode with reason for timing; include early return precautions]