What elements must be documented in a medication chart for an adult (≥50 years) patient with chronic pain, including dosing details, indication, treatment goals, side‑effects, opioid risk assessment, signed treatment agreement, urine drug screen, taper plan, rescue medication, non‑pharmacologic therapies, and review intervals?

Essential Documentation Elements for Chronic Pain Medication Charts in Adults ≥50 Years

For adults ≥50 years on chronic pain medications, your chart must document: complete medication list with dosing/indication/instructions, treatment goals with pain/function targets, side effects and management plan, opioid risk assessment with PDMP review, urine drug screening results, signed treatment agreement, morphine milligram equivalents (MME) calculation, rescue medication protocol, non-pharmacologic therapies, and scheduled reassessment intervals every 1-4 weeks initially then every 3 months. 1

Core Medication Documentation

Medication List Requirements

Document each prescribed medication with the following mandatory elements 1:

• Specific drug name, dose, route, and frequency (e.g., "Morphine sulfate 15 mg PO every 4 hours")
• Clear indication stating what each medication treats
• Explicit instructions on how and when to take each medication
• List of all medications to be discontinued to prevent confusion

Treatment Goals and Expectations

Before initiating opioids, document 1:

• Realistic goals for pain reduction (specific numeric targets on 0-10 scale)
• Functional improvement goals (e.g., "able to walk 2 blocks," "return to work")
• Discontinuation criteria if benefits do not outweigh risks
• Discussion of known risks including respiratory depression, addiction potential, cognitive effects, and common side effects
• Patient and clinician responsibilities for managing therapy

Opioid-Specific Safety Documentation

Risk Assessment and Monitoring

Check and document the state Prescription Drug Monitoring Program (PDMP) before starting opioids and review it with every prescription to every 3 months 1. This identifies dangerous combinations or dosages putting patients at overdose risk.

Calculate and document total morphine milligram equivalents (MME) per day 1:

• Use caution at any dosage
• Carefully reassess when reaching ≥50 MME/day
• Avoid or carefully justify ≥90 MME/day

Urine Drug Testing

Perform urine drug screening before starting opioid therapy and at least annually to assess for prescribed medications, other controlled substances, and illicit drugs 1. Document results and any discrepancies requiring intervention.

Treatment Agreement

Obtain a signed treatment agreement documenting patient understanding of 1:

• Opioid risks including overdose and addiction
• Single prescriber/pharmacy requirement
• Random drug testing expectations
• Safe storage and disposal
• No sharing medications
• Consequences of misuse

Dosing and Titration Documentation

Initial Prescribing

Prescribe immediate-release opioids instead of extended-release/long-acting formulations when starting therapy 1. Document:

• Lowest effective starting dose (e.g., morphine 5-15 mg PO or 2-5 mg IV for opioid-naïve patients) 1
• Rationale for opioid selection based on pain intensity, current therapy, and comorbidities 1

Rescue Medication Protocol

For patients on stable long-acting opioids, document 1:

• Rescue dose = 10-20% of total daily opioid dose
• Frequency: every hour as needed
• Reassessment timing: 60 minutes for oral, 15 minutes for IV administration
• Dose adjustment algorithm if pain persists after 2-3 rescue cycles

Side Effects Management

Prophylactic Measures

Document anticipatory management started simultaneously with opioid initiation 1:

• Bowel regimen: stimulating laxative ± stool softener for opioid-induced constipation
• Antiemetic plan for nausea/vomiting
• Monitoring plan for sedation and cognitive effects

Side Effect Monitoring List

Provide written instructions to contact provider for 1:

• New or worsening pain despite medication
• Nausea/vomiting preventing eating for 24 hours
• No bowel movement for 3 days
• Difficulty arousing patient during daytime (oversedation warning)
• Confusion or cognitive changes

High-Risk Situations Requiring Extra Documentation

Concurrent CNS Depressants

Avoid prescribing opioids with benzodiazepines or other CNS depressants whenever possible 1, 2. If unavoidable, document:

• Why safer alternatives are inadequate 2
• Specific overdose risk discussion with patient 2
• Naloxone prescription provided for home rescue 1, 2
• Plan for frequent reassessment (weekly initially) 2

Special Populations

Document medication adjustments for 1:

• Renal disease: avoid morphine due to accumulation of active metabolite morphine-6-glucuronide
• Hepatic insufficiency: avoid morphine, consider dose reductions
• Patients ≥60 years: increased NSAID toxicity risk requiring closer monitoring 1

Non-Pharmacologic Therapies

Document consideration and implementation of non-opioid approaches 1:

• Physical therapy, exercise programs
• Cognitive behavioral therapy
• Interventional procedures (nerve blocks, injections)
• Complementary therapies (acupuncture, massage)
• Rationale if not pursued (e.g., insurance limitations, patient refusal)

Reassessment Schedule

Initial Phase

Evaluate benefits and harms within 1-4 weeks of starting opioids or dose escalation 1. Document:

• Pain scores compared to baseline
• Functional improvement using validated tools (e.g., PEG scale)
• Side effects and tolerability
• Signs of opioid use disorder

Maintenance Phase

Reassess every 3 months or more frequently 1. Each visit must document:

• Current pain and function scores
• Determination to continue, taper, or stop based on benefit-harm balance
• PDMP review findings
• Urine drug screen results (at least annually)
• MME calculation
• Adherence assessment
• Adjustment plan

Critical Safety Documentation

Contact Information

Provide written list of 1:

• 24-hour contact numbers for reaching appropriate healthcare provider
• Specific instructions on when to call
• Emergency department guidance for severe symptoms

Taper Plan

If discontinuing or reducing opioids, document 1:

• Specific taper schedule (typically 10% dose reduction every 1-4 weeks)
• Rationale for taper
• Management of withdrawal symptoms
• Alternative pain management strategies

Common Pitfalls to Avoid

Never prescribe extended-release/long-acting opioids for acute pain or initial chronic pain treatment 1. These are only appropriate after pain is controlled with short-acting formulations 1.

Do not use equianalgesic conversion calculations directly when rotating opioids—dose the new opioid substantially lower due to incomplete cross-tolerance 1.

Avoid methadone without pain specialist consultation due to long, variable half-life (8-120 hours) and complex pharmacokinetics 1.