Journal of General Internal Medicine

, Volume 26, Issue 9, pp 958–964

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

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

DOI: 10.1007/s11606-011-1648-2

Cite this article as:
Starrels, J.L., Becker, W.C., Weiner, M.G. et al. J GEN INTERN MED (2011) 26: 958. doi:10.1007/s11606-011-1648-2



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 

Supplementary material

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

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Joanna L. Starrels
    • 1
  • 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

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