• Joanna L Starrels, William C Becker, Mark G Weiner, Xuan Li, Moonseong Heo, and Barbara J Turner.
• Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA. jostarre@montefiore.org
• J Gen Intern Med. 2011 Sep 1; 26 (9): 958964958-64.

Background/ObjectiveExperts 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.DesignRetrospective cohort using electronic medical records.ParticipantsPatients on long-term opioids (≥3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices.MethodsWe 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.Main ResultsOf 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).ConclusionPrimary care physicians' adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.

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