Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain

J Gen Intern Med. 2011 Sep;26(9):958-64. doi: 10.1007/s11606-011-1648-2. Epub 2011 Feb 24.


Background/objective: 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.

Design: Retrospective cohort using electronic medical records.

Participants: Patients on long-term opioids (≥3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices.

Methods: 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.

Main results: 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).

Conclusion: Primary care physicians' adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Analgesics, Opioid / therapeutic use*
  • Analgesics, Opioid / urine
  • Chronic Pain / drug therapy*
  • Chronic Pain / epidemiology
  • Chronic Pain / urine
  • Cohort Studies
  • Drug Evaluation, Preclinical / statistics & numerical data
  • Female
  • Humans
  • Inappropriate Prescribing / prevention & control
  • Male
  • Middle Aged
  • Office Visits / statistics & numerical data
  • Primary Health Care / methods*
  • Primary Health Care / standards
  • Retrospective Studies
  • Risk Factors
  • Risk Reduction Behavior*


  • Analgesics, Opioid