• Eleanor T Lewis, Ann Combs, and Jodie A Trafton.
• Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California 94025, USA. eleanor.lewis@va.gov
• Pain Med. 2010 Jun 1;11(6):861-71.

BackgroundWith the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do not take their medications as prescribed and find nonadherence rates of approximately 25%.ObjectiveTo identify the prevalence of under-use of opioid medications and the reasons and implications of under-use.DesignAs part of a variety of structured assessments, subjects were asked detailed questions about how they used their opioid medication in their daily lives.ParticipantsOne hundred ninety-one veterans who received an opioid prescription for any pain problem within the 12 months before the interview.MeasuresWe defined a patient who under-used his/her medication as one who took less than their prescribed dose of medication and reported that pain impaired their ability to engage in normal daily activities.ResultsUnder-use of opioids (20%) was more common than over-use (9%), consistent with research on medication adherence. Patients who under-used their opioids offered the same reasons for under-use that patients report for other medications. However, while under-users reported more pain than other opioid users they filled only slightly fewer opioid prescriptions. Communication problems between patients and providers about opioids were common.ConclusionsImproved communication between patients and providers and shared decision-making regarding opioid prescriptions may improve pain management and minimize the problems associated with over-prescription of opioids (i.e., diversion).

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