Prescription drug monitoring programs are generally underused in emergency departments (ED) and nationwide enrollment is low among emergency physicians. We aimed to develop consensus recommendations for prescription drug monitoring program policy and design to optimize their functionality and use in the ED. We assembled a technical expert panel with key stakeholders in emergency medicine, public health, and public policy. The panel included academic and community-based emergency physicians, a pediatric fellowship–trained emergency physician, a medical toxicologist, a public health expert, a patient advocate, a legal expert, and two state prescription drug monitoring program administrators. We compiled prescription drug monitoring program policies and characteristics and organized them into domains based on user–prescription drug monitoring program interaction. The panel convened for 3 rounds in which the policies and characteristics were introduced, discussed, and modified in an iterative fashion to achieve consensus. The process yielded policy recommendations and design features, with majority agreement. The panel made 18 policy recommendations within these main themes: enrollment should be mandatory, with an automatic process to mitigate the workload; registration should be open to all prescribers; delegates should have access to prescription drug monitoring program to alleviate work flow burdens; prescription drug monitoring program data should be pushed into hospital electronic health records; prescription drug monitoring program review should be mandatory for patients receiving opioid prescriptions and based on objective criteria; the prescription drug monitoring program content should be standardized and updated in a timely manner; and states should encourage interstate data sharing. An expert panel identified 18 recommendations that can be used by states and policymakers to improve prescription drug monitoring program design to increase use in the ED setting.