What medication management questions should be asked on follow-up of Medication-Assisted Recovery (MAR) treatment?

Medication Management Questions for MAR Follow-Up

At every MAR follow-up visit, clinicians must systematically assess treatment efficacy, medication adherence, adverse effects, signs of opioid use disorder, and whether benefits continue to outweigh risks—with initial follow-up within 1-4 weeks and ongoing reassessment at least every 3 months. 1

Initial Follow-Up (1-4 Weeks After Starting/Dose Changes)

Treatment Efficacy Assessment

• Pain control: Ask about average pain levels and whether pain relief is sustained throughout the dosing interval 1
• Functional improvement: Assess interference with enjoyment of life and general activity using structured tools like the PEG scale 1
• Progress toward functional goals: Ask specifically about meaningful activities the patient wanted to resume (work, family responsibilities, social engagement) 1
• Quality of life changes: Determine if overall well-being has improved since starting treatment 1

Critical pitfall: Patients without pain relief at 1 month are unlikely to experience benefit at 6 months, making this an essential decision point for continuing therapy 1

Medication Adherence Questions

• Missed doses: "How many days did you miss your medication in the last 4 days?" 2
• Weekend adherence: "Did you miss any doses last weekend?" 2
• Recent missed doses: "When was the last time you missed a dose in the past 3 months?" 2
• Dose timing: For methadone specifically, ask if the analgesic effect lasts the full dosing interval or if breakthrough pain occurs before the next dose 1, 3
• Self-administration patterns: "Are you taking the medication exactly as prescribed, or have you felt the need to take more or take it more frequently?" 1

Adverse Effects Screening

Common side effects to ask about at every visit: 1

• Constipation (most common—ask about bowel movements, hydration, fiber intake, need for stool softeners)
• Drowsiness or sedation
• Nausea or vomiting
• Dry mouth

Warning signs of serious complications requiring immediate attention: 1

• Sedation or slurred speech (early signs of overdose risk)
• Confusion or cognitive impairment
• Respiratory symptoms (shortness of breath, slow breathing)
• Syncope or seizures (particularly concerning with methadone) 4

Opioid Use Disorder Warning Signs

Ask directly about: 1

• Craving: "Do you find yourself thinking about or wanting the medication between doses?"
• Loss of control: "Have you had difficulty controlling your use or wanted to take more than prescribed?"
• Escalating use: "Have you taken opioids in greater quantities or more frequently than prescribed?"
• Functional impairment: "Have you had any work or family problems related to opioid use?"

Methadone-Specific Questions

For patients on methadone, additional critical assessments include: 1, 3, 4

• QTc monitoring: Obtain baseline ECG before treatment, follow-up within 30 days, and annually thereafter 4
• Dose adequacy for pain: "Does your methadone dose control pain for the full 24 hours, or does pain return before your next dose?" (methadone's analgesic duration is 6-8 hours despite 24-hour dosing for addiction treatment) 1
• Cardiac symptoms: Ask about palpitations, dizziness, or syncope at every visit 4
• Drug interactions: Review all medications, particularly those that prolong QT interval or inhibit methadone metabolism 4

Ongoing Reassessment (Every 3 Months Minimum)

Risk-Benefit Analysis

• Sustained benefit: "Are opioids still helping you meet your treatment goals for pain and function?" 1
• Patient preference: "Given the effects on your pain and function relative to any side effects, do you want to continue opioids?" 1
• Dose optimization: "Do you think we could reduce your dose while maintaining benefit?" 1

High-Risk Patient Monitoring

Patients requiring more frequent than 3-month follow-up include those with: 1

• Depression or other mental health conditions
• History of substance use disorder
• History of overdose
• Dosage ≥50 MME/day
• Concurrent benzodiazepines or other CNS depressants

These patients need reassessment more frequently than every 3 months 1

Substance Use Assessment

• Illicit opioid use: "Have you used any opioids not prescribed to you?" 5
• Other substance use: Ask about alcohol, benzodiazepines, cocaine, methamphetamine, marijuana 1
• Injection drug use: If applicable, ask about needle sharing and HIV/HCV risk behaviors 1, 5

Support System Evaluation

• Family awareness: "Who knows about your treatment?" 1
• Medication reminders: "What helps you remember to take your medication?" (family reminders and mobile phone alerts improve adherence) 2
• Recovery support: "Are you connected to peer support groups like Medication-Assisted Recovery Anonymous?" 6
• Logistical barriers: Ask about transportation to appointments, housing stability, and distance to providers 6

Red Flags Requiring Immediate Action

Discontinue or reduce dose if: 1

• QTc interval exceeds 500 ms (for methadone) 4
• Patient experiences overdose or serious adverse events
• No sustained improvement in pain and function
• High-risk regimen (≥50 MME/day or opioids with benzodiazepines) without clear benefit
• Patient requests dose reduction or discontinuation

Consider more intensive monitoring if: 1

• Starting or increasing ER/LA opioids (follow-up within 1 week)
• Starting or increasing methadone (follow-up within 3 days due to highest overdose risk in first 3-7 days)
• Total daily dose ≥50 MME/day

Documentation and Communication

For patients in opioid treatment programs (OTPs), obtain signed release to exchange information between prescribers before prescribing any controlled substances 1. Ongoing communication with the OTP is essential when multiple prescribers are involved 1.