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