Journal of General Internal Medicine

, Volume 26, Issue 9, pp 958–964 | Cite as

Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain

  • Joanna L. StarrelsEmail author
  • William C. Becker
  • Mark G. Weiner
  • Xuan Li
  • Moonseong Heo
  • Barbara J. Turner
Original Research



Experts recommend close oversight of patients receiving opioid analgesics for chronic non-cancer pain (CNCP), especially those at increased risk of misuse. We hypothesized that physicians employ opioid risk reduction strategies more frequently in higher risk patients.


Retrospective cohort using electronic medical records.


Patients on long-term opioids (≥3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices.


We examined three risk reduction strategies: (1) any urine drug test; (2) regular office visits (at least once per 6 months and within 30 days of modifying opioid treatment); and (3) restricted early refills (one or fewer opioid refills more than a week early). Risk factors for opioid misuse included: age <45 years old, drug or alcohol use disorder, tobacco use, or mental health disorder. Associations of risk factors with each outcome were assessed in non-linear mixed effects models adjusting for patient clustering within physicians, demographics and clinical factors.

Main Results

Of 1,612 patients, 8.0% had urine drug testing, 49.8% visited the office regularly, and 76.6% received restricted (one or fewer) early refills. Patient risk factors were: age <45 (29%), drug use disorder (7.6%), alcohol use disorder (4.5%), tobacco use (16.1%), and mental health disorder (48.4%). Adjusted odds ratios (AOR) of urine drug testing were significantly increased for patients with a drug use disorder (3.18; CI 1.94, 5.21) or a mental health disorder (1.73; CI 1.14, 2.65). However, the AOR for restricted early refills was significantly decreased for patients with a drug use disorder (0.56; CI 0.34, 0.92). After adjustment, no risk factor was significantly associated with regular office visits. An increasing number of risk factors was positively associated with urine drug testing (p < 0.001), but negatively associated with restricted early refills (p = 0.009).


Primary care physicians’ adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.


opioid misuse chronic pain urine drug testing 



This work was supported through the Program of Research Integrating Substance Use Issues into Mainstream Health Care (PRISM), funded by the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition, Dr. Starrels was supported in part by the Robert Wood Johnson Foundation Clinical Scholars Program and the Office of Veterans Affairs as a VA Special Fellow. The authors thank Evelyn Crowley, MS for contributing to data management and the Montefiore Division of General Medicine Substance Abuse Research Group for feedback during preparation of the manuscript. Preliminary results of this study were presented at the 32nd annual meeting of the Society of General Internal Medicine, Miami Beach, Florida, 13-16 May 2009.

Conflict of Interest

None disclosed.

Supplementary material

11606_2011_1648_MOESM1_ESM.pdf (42 kb)
ESM 1 (PDF 42 kb)


  1. 1.
    Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH Report: Patterns and trends in nonmedical prescription pain reliever use: 2002 to 2005. Rockland, MD.; (April 6, 2007): Accessed on January 20, 2011. Available from:
  2. 2.
    Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Highlights-- 2006 National Admissions to Substance Abuse Treatment Services. OAS Series #S-40, DHHS Publication No. (SMA) 08-4313, Rockville, MD, 2007.Google Scholar
  3. 3.
    Centers for Disease Control and Prevention. Unintentional Poisoning Deaths-- United States, 1999-2004. MMWR Morb Mortal Wkly Rep [serial on the Internet]. 56(5): Available from: Accessed on January 20 2011. Available from:
  4. 4.
    Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618–27.PubMedCrossRefGoogle Scholar
  5. 5.
    Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain. 2004;109(3):514–9.PubMedCrossRefGoogle Scholar
  6. 6.
    The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13:6–8.CrossRefGoogle Scholar
  7. 7.
    Federation of State Medical Boards of the United States. Model policy for the use of controlled substances for the treatment of pain. 2004.Google Scholar
  8. 8.
    Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–30.PubMedCrossRefGoogle Scholar
  9. 9.
    Sundwall DN, Rolfs RT, Johnson E. Utah Department of Health. Utah Clinical Guidelines of Prescribing Opioids for Treatment of Chronic Pain (2009). Salt Lake City, UT. Accessed January 20 2011. Available from:
  10. 10.
    Denisco RA, Chandler RK, Compton WM. Addressing the intersecting problems of opioid misuse and chronic pain treatment. Exp Clin Psychopharmacol. 2008;16(5):417–28.PubMedCrossRefGoogle Scholar
  11. 11.
    Starrels JL, Becker WC, Alford DA, Williams AR, Kapoor A, Turner BJ. Opioid treatment agreements and urine drug testing in chronic pain: a systematic review. Ann Intern Med. 2010;152:712–20.PubMedGoogle Scholar
  12. 12.
    Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):147–59.PubMedCrossRefGoogle Scholar
  13. 13.
    Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107–12.PubMedCrossRefGoogle Scholar
  14. 14.
    Ives TJ, Chelminski PR, Hammett-Stabler CA, Malone RM, Perhac JS, Potisek NM, Shilliday BB, DeWalt DA, Pignone MP. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46.PubMedCrossRefGoogle Scholar
  15. 15.
    Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007;129(3):355–62.PubMedCrossRefGoogle Scholar
  16. 16.
    Michna E, Jamison RN, Pham L-D, Ross EL, Janfaza D, Nedeljkovic SS, Narang S, Palombi D, Wasan AD. Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings. Clin J Pain. 2007;23(2):173–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Reid MC, Engles-Horton LL, Weber MB, Kerns RD, Rogers EL, O'Connor PG. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002;17(3):173–9.PubMedCrossRefGoogle Scholar
  18. 18.
    White AG, Birnbaum HG, Schiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Manag Care. 2009;15(12):897–906.PubMedGoogle Scholar
  19. 19.
    Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, Crosby AE, Paulozzi LJ. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300(22):2613–20.PubMedCrossRefGoogle Scholar
  20. 20.
    Morasco BJ, Dobscha SK. Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. Gen Hosp Psychiatry. 2008;30(2):93–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Michna E, Ross EL, Hynes WL, Nedeljkovic SS, Soumekh S, Janfaza D, Palombi D, Jamison RN. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage. 2004;28(3):250–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Wasan AD, Butler SF, Budman SH, Benoit C, Fernandez K, Jamison RN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain. 2007;23(4):307–15.PubMedCrossRefGoogle Scholar
  23. 23.
    Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85–92.PubMedGoogle Scholar
  24. 24.
    Yanni LM, Weaver MF, Johnson BA, Morgan LA, Harrington SE, Ketchum JM. Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic. J Opioid Manag. 2008;4(4):201–11.PubMedGoogle Scholar
  25. 25.
    Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32(3):287–93.PubMedCrossRefGoogle Scholar
  26. 26.
    U.S. Census Bureau; Census 2000, Summary File 3; generated by Joanna Starrels; using American FactFinder >>; (11 June 2008)
  27. 27.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27.PubMedCrossRefGoogle Scholar
  28. 28.
    Turner BJ, Hollenbeak CS, Weiner M, Ten Have T, Tang SS. Effect of unrelated comorbid conditions on hypertension management. Ann Intern Med. 2008;148(8):578–86.PubMedGoogle Scholar
  29. 29.
    Agresti A. Categorical Data Analysis, 2nd Edition. Hoboken, NJ: John Wiley & Sons, Inc; 2002.CrossRefGoogle Scholar
  30. 30.
    Adams NJ, Plane MB, Fleming MF, Mundt MP, Saunders LA, Stauffacher EA. Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22(3):791–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Bhamb B, Brown D, Hariharan J, Anderson J, Balousek S, Fleming MF. Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin. 2006;22(9):1859–65.PubMedCrossRefGoogle Scholar
  32. 32.
    Boulanger A, Clark AJ, Squire P, Cui E, Horbay GLA. Chronic pain in Canada: Have we improved our management of chronic noncancer pain? Pain Res Manage. 2007;12(1):39–47.Google Scholar
  33. 33.
    Touchet BK, Yates WR, Coon KA. Opioid contract use is associated with physician training level and practice specialty. J Opioid Manage. 2005;1(4):195–200.Google Scholar
  34. 34.
    Watkins A, Wasmann S, Dodson L, Hayes M. An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center. Fam Med. 2004;36(7):487–9.PubMedGoogle Scholar
  35. 35.
    Reisfield GM, Webb FJ, Bertholf RL, Sloan PA, Wilson GR. Family physicians' proficiency in urine drug test interpretation. J Opioid Manage. 2007;3(6).Google Scholar
  36. 36.
    Tellioglu T. The use of urine drug testing to monitor patients receiving chronic opioid therapy for persistent pain conditions. Med Health R I. 2008;91(9):279–80. 82.PubMedGoogle Scholar
  37. 37.
    Swanson J. Urine drug screening for opioids. J Pain Palliat Care Pharmacother. 2002;16(1):111–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, Fanciullo GJ. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097–102.PubMedCrossRefGoogle Scholar
  39. 39.
    Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of self-reported drug use in chronic pain patients. Clin J Pain. 1999;15(3):184–91.PubMedCrossRefGoogle Scholar
  40. 40.
    Atluri S, Sudarshan G. Evaluation of abnormal urine drug screens among patients with chronic non-malignant pain treated with opioids. Pain Physician. 2003;6:407–9.PubMedGoogle Scholar
  41. 41.
    Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage. 2004;27(3):260–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Sampson JM, Achololnu WW Jr. Reducing patient aggression and hostility in primary care with urine drug testing. South Med J. 2004;97(9):916–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Institute for Clinical Systems Improvement. Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record (July 2008). Bloomington, MN.: Accessed on January 20 2011. Available from:±AND±pain.
  44. 44.
    Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573–82.PubMedGoogle Scholar
  45. 45.
    Weisner CM, Campbell CI, Ray GT, Saunders K, Merrill JO, Banta-Green C, Sullivan MD, Silverberg MJ, Mertens JR, Boudreau D, Von Korff M. Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders. Pain. 2009;145(3):287–93.PubMedCrossRefGoogle Scholar
  46. 46.
    Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract. 2008;4(2):4–25.PubMedCrossRefGoogle Scholar
  47. 47.
    Compton PA, Wu SM, Schieffer B, Pham Q, Naliboff BD. Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance. J Pain Symptom Manage. 2008;36(4):383–95.PubMedCrossRefGoogle Scholar
  48. 48.
    Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–42. Nov-Dec.PubMedCrossRefGoogle Scholar
  49. 49.
    Holmes CP, Gatchel RJ, Adams LL, Stowell AW, Hatten A, Noe C, Lou L. An opioid screening instrument: long-term evaluation of the utility of the Pain Medication Questionnaire. Pain Pract. 2006;6(2):74–88.PubMedCrossRefGoogle Scholar
  50. 50.
    Belgrade MJ, Schamber CD, Lindgren BR. The DIRE Score: Predicting Outcomes of Opioid Prescribing for Chronic Pain. J Pain. 2006;7(9):671–81.PubMedCrossRefGoogle Scholar
  51. 51.
    Fishman SM, Bandman TB, Edwards A, Borsook D. The opioid contract in the management of chronic pain. J Pain Symptom Manage. 1999;18(1):27–37.PubMedCrossRefGoogle Scholar
  52. 52.
    Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid renewal clinic: A primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med. 2007;8(7):573–84.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Joanna L. Starrels
    • 1
    Email author
  • William C. Becker
    • 2
  • Mark G. Weiner
    • 3
  • Xuan Li
    • 1
  • Moonseong Heo
    • 1
  • Barbara J. Turner
    • 4
  1. 1.Division of General Internal MedicineAlbert Einstein College of Medicine and Montefiore Medical CenterBronxUSA
  2. 2.Yale University School of MedicineNew HavenUSA
  3. 3.University of Pennsylvania School of MedicinePhiladelphiaUSA
  4. 4.University of Texas Health Science Center and University Health SystemSan AntonioUSA

Personalised recommendations