One-liner#

A clear controlled-substance policy protects patients and clinicians; payer and state rules vary.

Core elements to standardize#

• Single prescriber and single pharmacy expectation (when feasible)
• Refill timing rules and lost/stolen policy
• Urine drug screening approach (risk-based)
• PDMP check documentation (cadence varies)
• Functional goals and periodic reassessment

Documentation checklist (each relevant visit)#

• Indication and functional benefit (not just pain score)
• Dose, quantity, and interval; any early refill rationale
• Safety counseling (sedation, driving, alcohol, overdose risk)
• Risk mitigation used (PDMP, UDS, naloxone, agreements as applicable)