Opioid Prescribing Requires Close Patient Monitoring by Kevin B. O’Reilly

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Opioid Prescribing Requires Close Patient Monitoring by Kevin B. O’Reilly

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Opioid analgesics help alleviate the symptoms of patients with chronic pain, but they are also vulnerable to abuse. About 14,000 people die annually from opioid overdoses, and the medicines are implicated in more than 300,000 emergency department visits each year, according to estimates from the Centers for Disease Control and Prevention.

To reduce the overdose risk, pain specialists advise that doctors prescribing opioids to patients with chronic pain monitor them closely to ensure that they do not misuse the drugs, especially if the patients have a history of substance abuse. But a study shows that some primary care doctors are not aggressive in pursuing monitoring strategies that could help prevent misuse and diversion.

For example, just 8% of 1,612 patients prescribed opioids by 203 physicians at eight Philadelphia-area clinics from 2004 to 2008 underwent urine drug screening during their treatment. Less than a quarter of the highest-risk patients were tested to see whether they were taking their medicines or using illicit substances. Less than half of all patients were seen at least once every six months, whereas about 53% of the riskier drug-history patients were seen that often.

“The most surprising finding was that physicians weren’t ratcheting up their use of risk-reduction strategies for patients who had a prior risk for opioid misuse,” said Joanna L. Starrels, MD, lead author of the study, published online Feb. 24 in the Journal of General Internal Medicine.

Most striking, Dr. Starrels said, was that patients with a history of drug abuse and other high-risk factors were the likeliest to receive multiple early opioid refills from their physicians. Experts consider frequent early refills a red flag for opioid misuse.

Guidelines issued by the American Pain Society and the American Academy of Pain Medicine in February 2009 call for close monitoring of patients prescribed chronic opioid therapy. Physicians should “periodically obtain urine drug screens” for high-risk patients and should consider doing so for all patients, the guidelines said. Doctors also were advised to periodically reassess patients taking opioids to ensure that they are meeting goal treatments and adhering to the prescribed therapies.

Urine drug screens can help physicians spot abuse, Dr. Starrels said. Between 21% and 44% of patients who demonstrate no red-flag behaviors have unexpected results on urine drug tests, according to urine drug tests, according to several studies. An additional 7.5% of patients test negative for the opioid drug they are prescribed, she said.

More training needed

It is critical that primary care physicians do what they can to reduce the risk of opioid misuse, said Dr. Starrels, assistant professor of medicine at the Albert Einstein College of Medicine of Yeshiva University in New York.

“Primary care physicians care for the majority of patients with chronic pain in the United States,” Dr. Starrels said. “While many experts say highrisk patients should see pain specialists, that’s not feasible. There aren’t enough of them.”

The new research demonstrates the necessity for more training of physicians prescribing opioids, experts said.

“This study substantiates the need for better education about assessing for and responding to abuse and diversion risks.” said Will Rowe, CEO of the American Pain Foundation, an organization that advocates for pain patients. “It’s not clear to me that these practitioners had a sense of the risks involved.”

The foundation in 2010 launched PainSAFE, a $1million-a-year initiative aimed at educating physicians and patients on safe use of opioids and other pain therapies. More training is available from the American Academy of Pain Medicine, which also is devoted to measuring outcomes, said Perry G. Fine, MD, the academy’s president.

The study’s findings are “very disturbing,” said Lynn Webster, MD, a board member of the academy.

“It is quite remarkable that in the face of an epidemic of drug abuse, diversion and an alarming rate of overdose deaths that prescribers are lackadaisical in their prescribing of opioids,” Dr. Webster said.

He added that it “may be time” to tie opioid prescribing privileges to mandatory education.

The Food and Drug Administration is considering a risk-reduction plan, known as a Risk Evaluation and Mitigation Strategy, to cut abuse and diversion of extended-release opioids.

Dr. Starrels said one important way to help primary care physicians is to give them standardized tools and protocols to use with all patients for whom they prescribe opioids, simplifying the job of keeping tabs on high-risk patients.

“Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain,” Journal of General Internal Medicine, published online Feb. 24 (www.ncbi.nim.nih.gov/ pubmed/21347877) “Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain,” Annals of Internal Medicine, June 1, 2010 (www.ncbi.nim.nih.gov/pubmed/ 20513829) “Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain, “ Journal of Pain, February 2009 (www.ncbi.nim.nih.gov/pubmed/19187889) American Pain Foundation’s PainSAFE initiative (www.painfoundation.org/painsafe) “Opioid drugs and risk evaluation and mitigation strategies,” Food and Drug Administration, September, 2010 (www.fda.gov/ drugs/drugsafetyinformationbydrugclass/ucm163647.htm) Re-printed by permission: the American Medical News/ 2011/03/21/prsb03, copyright 2011, American Medical Association. All rights reserved.


Response by Daniel C. Vinson, MD, Professor of Family and Community Medicine, University of Missouri, Columbia, and member of the MPHP’s Physicians’ Health Committee

Although things like urine drug testing haven’t been proven to improve outcomes, they have been strongly recommended by a consensus panel of experts. We need further research, but we shouldn’t wait for those studies to start doing what we can now. In my experience, routine drug testing helps set patient care in context (“We want to help you with your pain, and we need to do it safely”) and can open up the conversation (“When we check your urine, what’s it going to show?”).

These researchers studied only eight practice sites in one academic healthcare system. But if our readers are inclined to dismiss their findings, try applying their measures to our own practices.

Prescription drug abuse and diversion are increasing problems in the U.S. and in Missouri. We all need to seek to improve our own clinical routines.

Part of opioid misuse is due to addiction. That’s a treatable disease. With some study and a quiz, any physician can get certified to prescribe buprenorphine (Suboxone) which improves patients’ ability to stay off illicit opioids from 8.6% to 49.2%, a number needed to treat of only 2.5.