Opioid Risk Reduction Strategies Are Infrequently Used in Primary Care

Physicians need better tools for identifying patients at higher risk of opioid abuse and misuse, as well as better guidance on managing chronic pain patients.

Is the limited use of opioid risk reduction tools in the primary care setting due to providers shunning the use of these tools because of a lack of good quality evidence supporting their effectiveness, or do primary care providers “lack a systematic way of identifying high-risk patients who need to be monitored closely?”

These and other questions were raised by the authors of “Limited Use of Opioid Risk Reduction Strategies in Primary Care,” published in the May 2011 issue of the Journal of Clinical Outcomes Management. In this article, the authors reviewed data from another study (“Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain,” published in the Journal of General Internal Medicine) that evaluated the frequency of use of three opioid risk reduction strategies in the primary care setting: urine drug testing, regular office visits, and restricted early refills. In the original study, which involved 1,612 mostly female and African American patients who were receiving long-term opioid treatment at eight urban or suburban primary care practices within the University of Pennsylvania Health System, patients had been receiving opioid treatment for nearly two years on average, with the average patient receiving 20 prescriptions for opioid medications during the study period.

Also see “African American Patients Screened More Frequently for Opioid Abuse” for more information from this study.

The original study authors reported opioid misuse risk factors prevalence scores of “29.1% for age < 45 years, 7.6% for drug use disorder, 4.5% for alcohol use disorder, 16.1% for tobacco use disorder, and 48.8% for mental health disorder.” Few (8.4%) patients had three or more risk factors.

In the study, only 8% of patients received urine drug testing, slightly less than half (49.8%) had regular office visits, and more than three-quarters (76.6%) had restricted early medication refills. Less than 3% of patients received all three risk reduction measures. Patients with a drug use or mental health disorder were more likely to receive urine drug testing. Drug users were actually less likely to receive restricted early refills.

With the rising number of prescriptions for opioid medications for the treatment of chronic non-cancer pain matched by increasing rates of opioid misuse and abuse, it would seem that clinicians and their patients would be well served by implementing opioid risk reduction strategies in practice. However, “limited good-quality evidence exists on the use of opioid analgesic risk reduction strategies in primary care settings,” with recent studies.” Despite this, experts “support the use of opioid risk reduction strategies, even though they are imperfect, to reduce opioid misuse.”

In their commentary on the original study, the authors of the review article in the Journal of Clinical Outcomes Management noted that the presence of several opioid misuse risk factors did not make it more likely that patients would receive urine drug screening or be required to attend regular office visits for follow-up and monitoring. From these results, it is “unclear if limited use of these tools is a reflection of inadequate evidence to support using them in primary care settings,” or if primary care providers “lack a systematic way of identifying high-risk patients who need to be monitored closely.” Still, despite the absence of good quality risk identification tools, the review authors wrote that this study suggests that primary care physicians “should use all the existing, albeit imperfect, opioid risk reduction strategies to monitor for opioid analgesic misuse.”

The poor utilization rate for opioid risk reduction strategies in this study, despite the prevalence of several clear risk factors for opioid misuse and abuse among the study population, suggests “the need for better quality tools to identify patients at risk of misuse and a more standardized approach to addressing chronic pain management in primary care.” The review authors noted the successes achieved with the multidisciplinary “Opioid Renewal Clinic” approach adopted at one Veterans Administration medical practice as one possible option.