Initial Patient Visit Narcotic Prescribing Checklist
1. Complete history and physical are obtained
2. Old records are reviewed: when possible, have your office obtain these via fax
3. Make certain there is a legitimate medical diagnosis which would necessitate
the use of narcotics.
4. Document other non-narcotic therapies have already been tried and failed
5. Document the level of pain and the functional incapacity associated
6. Develop a plan of therapeutic intervention and document that plan
7. Opiate agreement should be signed before receiving any narcotics
8. Note red flag and yellow flag signs below prior to prescribing
RED FLAGS: DO NOT PRESCRIBE NARCOTICS!!!!
No available prior medical records
Will not divulge name or sign information release for prior physician’s records Note: Some
patients will claim rights to privacy under HIPPA. But their rights do not trump your
responsibility to insure narcotics are being prescribed for a legitimate medical purpose and
that there is no significant history of substance abuse, diversion, or psychiatric disease.
Refuses all psychological, physical therapy evaluations and interventional techniques
Needle track marks, skin pop marks
History of selling narcotics, forging prescriptions, manufacture of methamphetamine or other illegal
drugs
Patient travels hundreds of miles to see you when there are many other pain physicians closer to
the patient's home
Previously discharged from your practice for substance abuse or diversion
YELLOW FLAGS: TREAT WITH GREAT CAUTION
Patients with substance abuse history (alcohol or any drug, legal or illegal) need continuous
multidisciplinary care including psychology or addictionology in addition to frequent visits early on
and random drug screens. Do NOT prescribe narcotics to these patients without first obtaining
psychological consultation regarding the appropriateness of narcotic therapy.
Consider urine drug screen on first visit prior to prescribing any narcotics in patients who are self-
referred or in those without a primary care physician.
Patients who are "allergic" to nearly every narcotic you name except the one they want should be
treated with great suspicion, especially if you mention new narcotics they could not have possibly
tried yet. Patients who request name brand should be told that is contrary to your medical
practice. (Name brands have a much greater street recognition and therefore increased street
value)
Young patients ages 20-30. (Have a statistically significant increase in illicit drug use, binge
drinking both of which may result in overdose when combined with narcotics. This age group has
300% the substance abuse of the 40-50 age group.
Smokers have 500% the substance abuse of non-smokers.
The unemployed have 300% the substance abuse vs. full time employed.
Those with serious mental illness have 300% the substance abuse rate vs. those without serious
mental illness.
Personal or social maladjustment, depression, personality disorder, or a family history of addictive
problems may predispose somewhat to prescription medication abuse.
The Medicaid population is much more at risk for substance abuse or diversion. They have a
different social compass, have little to lose by selling the narcotics prescribed, and do not
subscribe to the same level of responsibility for their own health preservation as the non-Medicaid
population