Primary care doctors do limited screening for misuse of long-term opioids

Primary care physicians' adoption of opioid risk reduction strategies is limited, even in treatment of patients at increased risk of misuse, a new study has found.

Researchers conducted a retrospective cohort study using data from eight primary care practices sharing an electronic health record within the University of Pennsylvania Health System from January 2004 to April 2008. Patients were 18 years of age and older, had three or more visits, needed three or more opioid prescriptions at least 21 days apart within 6 months, and had chronic, non-cancer pain. Of 1,612 patients, most were female, black, and resided in ZIP codes where median household income was below $35,000 per year.

Researchers studied three risk reduction strategies and five risk factors for opioid misuse. The risk reduction strategies included any urine drug test, regular office visits at least once every 6 months and within 30 days of modifying opioid treatment, and restricted early refills of one or fewer opioid prescriptions more than a week early. Risk factors for opioid misuse included age younger than 45 years, drug or alcohol use disorder, tobacco use, or mental health disorder. Results appeared in the September Journal of General Internal Medicine.

The mean duration of observed opioid treatment was 1.9 years, and 54.5% of the cohort was treated for at least 18 months. During this time, patients received a mean of 20.2 opioid prescriptions. Within the study cohort, 8.0% had at least one urine drug test, 49.8% had regular office visits, and 76.6% had restricted early refills. Overall, 44 (2.7%) of the cohort received all three risk reduction strategies. Prevalence of risk factors for opioid misuse was 29.1% for age younger than 45 years, 7.6% for drug use disorder, 4.5% for alcohol use disorder, 16.1% for tobacco use, and 48.4% for mental health disorder.

The authors wrote, “Overall, our findings reveal disturbingly low use of monitoring strategies to reduce the risk of adverse events from long-term opioid treatment and indicate that primary care physicians are not employing all these approaches more intensively for patients at increased risk of misuse.”

Although patients at increased risk of opioid misuse were more likely to undergo urine tests, less than one-quarter of patients with three or more risk factors had any urine drug test. Patients at increased risk of opioid misuse were more likely to receive more than one early refill, and their office-based monitoring was no greater than for persons with no risk factors. “This lack of face-to-face encounters represents missed opportunities for physicians to examine responses to treatment, propose alternative treatments when response is inadequate, detect side effects, and assess for misuse,” the authors wrote.

Editorialists commented, “The increasing prevalence of misuse of and addiction to prescription opioid analgesics attributable to physician prescription appears to be the result of a perfect storm: inconsistent and inadequate physician education, lack of sufficient evidence of efficacy and safety of opioid analgesia for chronic pain, and lack of adherence to guideline-based risk assessment and monitoring.”

A systemic approach included monitoring all patients, basing intensity on risk factors. Primary care clinicians should collaborate with clinicians in behavioral health, pharmacists and addiction specialists when misuse occurs. Finally, patients must be better educated on the risks and their mitigation strategies, the authors said.

Tips on universal monitoring and care collaboration appeared in ACP Internist's May 2011 issue, and more pearls for opioid management appeared in its June 2010 issue.