Journal of General Internal Medicine

, Volume 29, Issue 2, pp 305–311

Chronic Opioid Therapy Risk Reduction Initiative: Impact on Urine Drug Testing Rates and Results

  • Judith A. Turner
  • Kathleen Saunders
  • Susan M. Shortreed
  • Suzanne E. Rapp
  • Stephen Thielke
  • Linda LeResche
  • Kim M. Riddell
  • Michael Von Korff
Original Research



In response to epidemic levels of prescription opioid overdose, abuse, and diversion, routine urine drug tests (UDTs) are recommended for patients receiving chronic opioid therapy (COT) for chronic pain. However, UDT ordering for COT patients is inconsistent in primary care, and little is known about how to increase UDT ordering or the impact of increased testing on rates of aberrant results.


To compare rates and results of UDTs for COT patients before versus after implementation of an opioid risk reduction initiative in a large healthcare system.


Pre-post observational study.


Group Health patients on COT October 2008–September 2009 (N = 4,821), October 2009–September 2010 (N = 5,081), and October 2010–September 2011 (N = 5,498).


Multi-faceted opioid risk reduction initiative.


Annual rates of UDTs and UDT results.


Half of COT patients received at least one UDT in the year after the initiative was implemented, compared to only 7 % 2 years prior. The adjusted odds of COT patients having at least one UDT in the first year of the opioid initiative were almost 16 times (adjusted OR = 15.79; 95 % CI: 13.96–17.87) those 2 years prior. The annual rate of UDT detection of marijuana and illicit drugs did not change (12.6 % after initiative implementation), and largely reflected marijuana use (detected in 11.1 % of all UDTs in the year after initiative implementation). In the year after initiative implementation, 10.7 % of UDTs were negative for opioids.


The initiative appeared to dramatically increase urine drug testing of COT patients in the healthcare system without impacting rates of aberrant results. The large majority of aberrant results reflected marijuana use or absence of opioids in the urine. The utility of increased urine drug testing for COT patient safety and prevention of diversion remains uncertain.


urine drug test urine drug screen chronic opioid therapy chronic pain opioid risk reduction 


  1. 1.
    Starrels JL, Becker WC, Alford DP, Kapoor A, Williams A, Turner BJ. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712–20.PubMedCrossRefGoogle Scholar
  2. 2.
    Warner M, Chen LH, Makuc DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no. 81. Hyattsville, MD, 2011.Google Scholar
  3. 3.
    Starrels J, Becker W, Weiner M, Li X, Heo M, Turner B. Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med. 2011;26:958–64.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–21.PubMedCrossRefGoogle Scholar
  5. 5.
    Volkow ND, McLellan TA. Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA. 2011;305(13):1346–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309:657–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. The DAWN report: highlights of the 2010 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Rockville, MD, July 2, 2012.Google Scholar
  8. 8.
    Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS) 1999–2009: National Admissions to Substance Abuse Treatment Services [Accessed September 5, 2013]. Available at:
  9. 9.
    Rolfs RT, Johnson E, Williams NJ, Sundwall DN. Utah clinical guidelines on prescribing opioids for treatment of pain. J Pain Palliat Care Pharmacother. 2010;24(3):219–35.PubMedCrossRefGoogle Scholar
  10. 10.
    Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Bair MJ, Krebs EE. Why is urine drug testing not used more often in practice? Pain Pract. 2010;10(6):493–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010;151:625–32.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    McCracken LM, Boichat C, Eccleston C. Training for general practitioners in opioid prescribing for chronic pain based on practice guidelines: a randomized pilot and feasibility trial. J Pain. 2012;13(1):32–40.PubMedCrossRefGoogle Scholar
  14. 14.
    Hanbury A, Wallace L, Clark M. Use of a time series design to test effectiveness of a theory-based intervention targeting adherence of health professionals to a clinical guideline. Br J Health Psychol. 2009;14(3):505–18.PubMedCrossRefGoogle Scholar
  15. 15.
    Trescott CE, Beck RM, Seelig MD, Von Korff M. Group Health’s initiative to avert opioid misuse and overdose among patients with chronic noncancer pain. Health Aff. 2011;30:1420–4.CrossRefGoogle Scholar
  16. 16.
    Von Korff M, Saunders K, Ray GT, et al. De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008;24:521–7.PubMedCrossRefGoogle Scholar
  17. 17.
    McCullagh P, Nelder JA. Generalized Linear Models. London: Chapman & Hall; 1989.CrossRefGoogle Scholar
  18. 18.
    Liang JK-Y, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.CrossRefGoogle Scholar
  19. 19.
    Zeger SL, Liang JK-Y. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42:121–30.PubMedCrossRefGoogle Scholar
  20. 20.
    Cone EJ, Caplan YH. Urine toxicology testing in chronic pain management. Postgrad Med. 2009;121:91–102.PubMedCrossRefGoogle Scholar
  21. 21.
    Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66–76.PubMedCrossRefGoogle Scholar
  22. 22.
    Tenore PL. Advanced urine toxicology testing. J Addict Dis. 2010;29(4):436–48.PubMedCrossRefGoogle Scholar
  23. 23.
    Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007;22:485–90.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Reisfield GM, Wasan AD, Jamison RN. The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. Pain Med. 2009;10(8):1434–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Pesce A, West C, Gonzales E, et al. Illicit drug use correlates with negative urine drug test results for prescribed hydrocodone, oxycodone, and morphine. Pain Physician. 2012;15:E687–92.PubMedGoogle Scholar
  26. 26.
    Alford DP. Chronic back pain with possible prescription opioid misuse. JAMA. 2013;309(9):919–25.PubMedCrossRefGoogle Scholar
  27. 27.
    Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37(4):301–14.PubMedGoogle Scholar
  28. 28.
    McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict. 2010;19(1):4–16.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123–43.PubMedGoogle Scholar
  30. 30.
    Washington State Agency Medical Directors’ Group. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid therapy, 2010 update. Olympia, WA. 2010. Accessed September 5 2013.
  31. 31.
    Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of self-reported drug use in chronic pain patients. Clin J Pain. 1999;15:184–91.PubMedCrossRefGoogle Scholar
  32. 32.
    Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1097–102.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Judith A. Turner
    • 1
    • 2
    • 3
  • Kathleen Saunders
    • 4
  • Susan M. Shortreed
    • 4
  • Suzanne E. Rapp
    • 3
  • Stephen Thielke
    • 1
    • 5
  • Linda LeResche
    • 6
  • Kim M. Riddell
    • 7
  • Michael Von Korff
    • 4
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  2. 2.Department of Rehabilitation MedicineUniversity of WashingtonSeattleUSA
  3. 3.Department of Anesthesiology and Pain MedicineUniversity of WashingtonSeattleUSA
  4. 4.Group Health Research InstituteSeattleUSA
  5. 5.Geriatric Research, Education, and Clinical Center, Puget Sound Veterans Affairs Medical CenterSeattleUSA
  6. 6.Department of Oral MedicineUniversity of WashingtonSeattleUSA
  7. 7.Group HealthSeattleUSA

Personalised recommendations