Over the past decade, the clinical and regulatory environment surrounding opioid prescribing for chronic non-cancer pain has changed substantially. The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain and, more significantly, the updated 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain established a clearer framework for risk-benefit assessment, dosage considerations, monitoring, and documentation. These guidelines, combined with sustained scrutiny by the Drug Enforcement Administration (DEA), state medical boards, payers, and pharmacies, now define the prevailing standard of care. Practices that do not systematically address these expectations risk appearing as outliers and inviting further review.
Opioid therapy continues to have a legitimate role for carefully selected patients when the expected benefits in pain reduction and functional improvement outweigh the risks. However, the intensity of external oversight means that how opioids are prescribed and monitored is now as important as whether they are prescribed.
Morphine milligram equivalents (MME) and elevated risk
Although morphine milligram equivalent (MME) calculations have recognized limitations, they function as a practical and widely applied metric used by regulators, pharmacy benefit managers, and payers. The 2022 CDC guideline notes that many patients do not experience meaningful additional benefit above 50 MME/day while facing progressive increases in overdose risk. Observational data summarized in the guideline show that dosages of 50 to <100 MME/day are associated with 1.9 to 4.6 times higher overdose risk compared with dosages of 1 to <20 MME/day, with further increases at ≥100 MME/day. Consequently, patients maintained at or above 50 MME/day appropriately trigger heightened expectations for documentation, risk assessment, and more frequent monitoring. The CDC specifically recommends that clinicians reassess benefits and risks more frequently than every three months for patients taking ≥50 MME/day or who have other risk factors.
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Complexity of opioid-management visits and limitations of monthly follow-up
A follow-up encounter for a patient receiving ongoing opioid therapy is clinically and administratively more complex than a routine non-opioid follow-up. In addition to reassessing the underlying pain generator and functional status, the visit must typically include:
- Review of the state prescription drug monitoring program (PDMP; CURES in California) to evaluate concurrent prescriptions and potential risk combinations
- Interpretation of urine drug toxicology (UDT) results to assess adherence and detect unexpected substances
- Explicit documentation of benefit versus risk, functional outcomes, and medical decision-making regarding continuation, adjustment, or taper
- Assessment for aberrant behaviors or emerging substance-use concerns
These elements align with recommendations 9 and 10 of the 2022 CDC guideline and with specialty society guidance on risk-stratified monitoring. Even a thorough 15- to 20-minute monthly visit cannot fully bridge a 30-day interval. A pilot trial of electronic medication-event monitoring systems (MEMS) in chronic pain patients on long-term opioid therapy demonstrated highly heterogeneous dosing patterns, including rapid removal of excessive quantities and stockpiling, patterns that were largely undetected by physician clinical impressions, self-report, and even urine drug screening. Traditional intermittent monitoring therefore systematically under-detects non-adherence and potential misuse. Escalating use, loss of control, emerging side effects, declining function, or early signs of diversion can develop between visits and remain undetected until the next scheduled encounter, or until an adverse event occurs.
Importance of remote therapeutic monitoring (RTM) for patients ≥50 MME/day
For patients maintained at or above 50 MME/day, the combination of higher overdose risk and the documented limitations of intermittent clinic-based assessment creates a clear clinical and operational rationale for enhanced monitoring between visits. Remote therapeutic monitoring (RTM) enables clinical review of non-physiologic data highly relevant to pain management: pain scores, functional status, therapy adherence, medication response, and related symptoms.
Supporting evidence for more continuous or digital monitoring approaches includes the following:
- Real-time electronic monitoring reveals substantially greater non-adherence than is detected by conventional methods, supporting the value of objective, frequent data capture over reliance on monthly self-report or clinic impressions.
- Digital and online pain self-management interventions have been shown in a randomized trial to increase the likelihood of clinically meaningful opioid dose reductions while simultaneously improving or maintaining pain control and self-efficacy.
- Continuous or near-continuous digital monitoring of chronic pain trajectories provides superior insight into long-term patterns compared with baseline assessments alone; baseline clinical variables often have limited predictive value for subsequent trajectories, underscoring the need for ongoing data collection.
- Mobile health and remote monitoring interventions in chronic pain populations have been associated with improved medication adherence, reduced opioid and non-opioid medication use, and better detection of concerning trends that can prompt earlier clinical intervention.
- In related high-risk opioid settings (including postoperative and inpatient care), continuous or enhanced surveillance monitoring has been associated with marked reductions in opioid-related respiratory depression events and mortality when compared with intermittent monitoring.
Collectively, these findings indicate that more frequent data collection between office visits improves the ability to identify problems early, support safe dose management, document ongoing benefit versus risk, and intervene before adverse events occur. For patients at ≥50 MME/day, which is the population already identified by the CDC as warranting more frequent reassessment, RTM provides a practical mechanism to operationalize that recommendation.
Clinical and practice benefits
Implementation of RTM for higher-MME patients offers several advantages:
- Strengthens the clinical justification for continued opioid therapy by generating longitudinal rather than point-in-time data.
- Enables earlier detection of escalating use, declining function, non-adherence, or other risk signals.
- Differentiates the intensity and complexity of care provided to patients on higher-dose opioids from that provided to patients not receiving opioid therapy.
- Demonstrates a proactive, risk-mitigation posture consistent with current regulatory expectations, thereby supporting both patient safety and the defensibility of the practice should review occur.
In summary, conscientious opioid prescribing requires more than appropriate patient selection. It requires structured monitoring that matches both the elevated clinical risk associated with dosages ≥50 MME/day and the degree of external scrutiny now attached to this therapy. Systematic PDMP and UDT review at visits, combined with RTM between visits for higher-MME patients, represents a practical, evidence-aligned, and defensible standard. It prioritizes patient safety while supporting the long-term sustainability and regulatory resilience of the practice.
Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.
Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.
Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.
