Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain
- 615 Downloads
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.
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.
KEY WORDSopioid 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
- 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: http://oas.samhsa.gov/2k7/pain/pain.pdf
- 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.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: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5605a1.htm.
- 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.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.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: http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines_summary.pdf.
- 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
- 26.U.S. Census Bureau; Census 2000, Summary File 3; generated by Joanna Starrels; using American FactFinder >http://factfinder.census.gov/>; (11 June 2008)
- 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.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
- 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
- 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: http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=13005&string=urine±AND±pain.