Reviews1 June 2010
    Author, Article and Disclosure Information
    Background:

    Experts recommend opioid treatment agreements and urine drug testing to reduce opioid analgesia misuse, but evidence of their effectiveness has not been systematically reviewed.

    Purpose:

    To synthesize studies of the association of treatment agreements and urine drug testing with opioid misuse outcomes in outpatients with chronic noncancer pain.

    Data Sources:

    MEDLINE, PsycINFO, EMBASE, Cochrane Central Register of Controlled Clinical Trials (January 1966 to June 2009), reference lists, and expert contacts.

    Study Selection:

    Original research addressing opioid medications, chronic pain, and treatment agreements or urine drug testing, with a sample size of 50 participants or more and published in English, Spanish, or French.

    Data Extraction:

    Two investigators independently identified eligible studies, extracted data, and assessed study quality. The outcome of opioid misuse was defined as drug abuse, drug misuse, aberrant drug-related behavior, diversion, or addiction.

    Data Synthesis:

    Of 102 eligible studies, 11 met inclusion criteria; 6 were in pain clinics and 5 were in primary care settings. Four primary care studies examined multicomponent strategies that included interdisciplinary support. All studies were observational and rated as poor to fair quality. In 4 studies with comparison groups, opioid misuse was modestly reduced (7% to 23%) after treatment agreements with or without urine drug testing. In the other 7 studies, the proportion of patients with opioid misuse after treatment agreements, urine drug testing, or both varied widely (3% to 43%).

    Limitations:

    Diversity of interventions and opioid misuse measures precluded meta-analysis. Most studies evaluated combinations of interventions.

    Conclusion:

    Relatively weak evidence supports the effectiveness of opioid treatment agreements and urine drug testing in reducing opioid misuse by patients with chronic pain. Further research on effective ways to monitor and reduce opioid misuse is needed, especially in primary care settings.

    Primary Funding Source:

    Substance Abuse and Mental Health Services Administration, National Institute on Drug Abuse, and Robert Wood Johnson Foundation.

    References

    • 1. Caudill-Slosberg MA Schwartz LM Woloshin S Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain2004;109:514-9. [PMID: 15157714] CrossrefMedlineGoogle Scholar
    • 2. Cherry DK Woodwell DA Rechtsteiner EA National Ambulatory Medical Care Survey: 2005 summary. Adv Data2007;:1-39. [PMID: 17703793] MedlineGoogle Scholar
    • 3. Clark JD Chronic pain prevalence and analgesic prescribing in a general medical population. J Pain Symptom Manage2002;23:131-7. [PMID: 11844633] CrossrefMedlineGoogle Scholar
    • 4. Elliott AM Smith BH Penny KI Smith WC Chambers WA The epidemiology of chronic pain in the community. Lancet1999;354:1248-52. [PMID: 10520633] CrossrefMedlineGoogle Scholar
    • 5. Gureje O Von Korff M Simon GE Gater R Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA1998;280:147-51. [PMID: 9669787] CrossrefMedlineGoogle Scholar
    • 6. Olsen Y Daumit GL Ford DE Opioid prescriptions by U.S. primary care physicians from 1992 to 2001. J Pain2006;7:225-35. [PMID: 16618466] CrossrefMedlineGoogle Scholar
    • 7. Zerzan JT Morden NE Soumerai S Ross-Degnan D Roughead E Zhang F et alTrends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002. Med Care2006;44:1005-10. [PMID: 17063132] CrossrefMedlineGoogle Scholar
    • 8. IMS Health. 2008 Top Therapeutic Classes by U.S. Dispensed Prescriptions. Accessed at www.imshealth.com/portal/site/imshealth/menuitem.a46c6d4df3db4b3d88f611019418c22a/?vgnextoid=85f4a56216a10210VgnVCM100000ed152ca2RCRD&cpsextcurrchannel=1 on 16 April 2010. Google Scholar
    • 9. Portenoy RK Foley KM Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain1986;25:171-86. [PMID: 2873550] CrossrefMedlineGoogle Scholar
    • 10. Martell BA O'Connor PG Kerns RD Becker WC Morales KH Kosten TR et alSystematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med2007;146:116-27. [PMID: 17227935] LinkGoogle Scholar
    • 11. Ballantyne JC Mao J Opioid therapy for chronic pain. N Engl J Med2003;349:1943-53. [PMID: 14614170] CrossrefMedlineGoogle Scholar
    • 12. Eisenberg E McNicol ED Carr DB Efficacy and safety of opioid agonists in the treatment of neuropathic pain of nonmalignant origin: systematic review and meta-analysis of randomized controlled trials. JAMA2005;293:3043-52. [PMID: 15972567] CrossrefMedlineGoogle Scholar
    • 13. Noble M Tregear SJ Treadwell JR Schoelles K Long-term opioid therapy for chronic noncancer pain: a systematic review and meta-analysis of efficacy and safety. J Pain Symptom Manage2008;35:214-28. [PMID: 18178367] CrossrefMedlineGoogle Scholar
    • 14. Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health Report: Patterns and Trends in Nonmedical Prescription Pain Reliever Use: 2002 to 2005. Rockville, MD: Office of Applied Studies; 2008. NSDUH Series H-34, DHHS publication no. SMA 08-4343. Accessed at www.oas.samhsa.gov/2k7/pain/pain.pdf on 20 April 2010. Google Scholar
    • 15. Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS) Highlights—2006 National Admissions to Substance Abuse Treatment Services. Rockville, MD: U.S. Department of Health and Human Services; 2007. OAS Series #S-40, DHHS publication no. SMA 08-4313. Google Scholar
    • 16. Drug Abuse Warning Network. The DAWN Report. National Estimates of Drug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Rockville, MD: Substance Abuse and Mental Health Services Administration. Accessed at dawninfo.samhsa.gov/files/ED2006/DAWN2k6ED.pdf on 20 April 2010. Google Scholar
    • 17. Centers for Disease Control and Prevention (CDC)Unintentional poisoning deaths—United States, 1999-2004. MMWR Morb Mortal Wkly Rep2007;56:93-6. [PMID: 17287712] MedlineGoogle Scholar
    • 18. Gilson AM Ryan KM Joranson DE Dahl JL A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. J Pain Symptom Manage2004;28:176-88. [PMID: 15276196] CrossrefMedlineGoogle Scholar
    • 19. The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain1997;13:6-8. [PMID: 9084947] MedlineGoogle Scholar
    • 20. Chou R Fanciullo GJ Fine PG Adler JA Ballantyne JC Davies P et alAmerican Pain Society-American Academy of Pain Medicine Opioids Guidelines PanelClinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain2009;10:113-30. [PMID: 19187889] CrossrefMedlineGoogle Scholar
    • 21. Model Policy for the Use of Controlled Substances for the Treatment of Pain. Federation of State Medical Boards of the United States; 2004. Accessed at www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf on 25 April 2010. Google Scholar
    • 22. Gourlay DL Heit HA Almahrezi A Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med2005;6:107-12. CrossrefMedlineGoogle Scholar
    • 23. Adams NJ Plane MB Fleming MF Mundt MP Saunders LA Stauffacher EA Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage2001;22:791-6. CrossrefMedlineGoogle Scholar
    • 24. Bhamb B Brown D Hariharan J Anderson J Balousek S Fleming MF Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin2006;22:1859-65. CrossrefMedlineGoogle Scholar
    • 25. Boulanger A Clark AJ Squire P Cui E Horbay GL Chronic pain in Canada: have we improved our management of chronic noncancer pain? Pain Res Manag2007;12:39-47. CrossrefMedlineGoogle Scholar
    • 26. Linzer M Manwell LB Williams ES Bobula JA Brown RL Varkey AB et alMEMO (Minimizing Error, Maximizing Outcome) InvestigatorsWorking conditions in primary care: physician reactions and care quality. Ann Intern Med2009;151:28-36, W6-9. LinkGoogle Scholar
    • 27. Bair MJ Overcoming fears, frustrations, and competing demands: an effective integration of pain medicine and primary care to treat complex pain patients [Editorial]. Pain Med2007;8:544-5. CrossrefMedlineGoogle Scholar
    • 28. Willi C Bodenmann P Ghali WA Faris PD Cornuz J Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis. JAMA2007;298:2654-64. CrossrefMedlineGoogle Scholar
    • 29. Ballantyne JC LaForge KS Opioid dependence and addiction during opioid treatment of chronic pain. Pain2007;129:235-55. CrossrefMedlineGoogle Scholar
    • 30. Downs SH Black N The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health1998;52:377-84. CrossrefMedlineGoogle Scholar
    • 31. Jadad AR Moore RA Carroll D Jenkinson C Reynolds DJ Gavaghan DJ et alAssessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials1996;17:1-12. CrossrefMedlineGoogle Scholar
    • 32. Fung CH Lim YW Mattke S Damberg C Shekelle PG Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med2008;148:111-23. LinkGoogle Scholar
    • 33. Atkins D Briss PA Eccles M Flottorp S Guyatt GH Harbour RT et alGRADE Working GroupSystems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system. BMC Health Serv Res2005;5:25. [PMID: 15788089] CrossrefMedlineGoogle Scholar
    • 34. Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.0.1 (updated September 2008). The Cochrane Collaboration; 2008. Accessed at www.cochrane-handbook.org on 20 April 2010. Google Scholar
    • 35. Goldberg KC Simel DL Oddone EZ Effect of an opioid management system on opioid prescribing and unscheduled visits in a large primary care clinic. J Clin Outcomes Management2005;12:621-28. Google Scholar
    • 36. Wiedemer NL Harden PS Arndt IO Gallagher RM The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Med2007;8:573-84. CrossrefMedlineGoogle Scholar
    • 37. Manchikanti L Manchukonda R Damron KS Brandon D McManus CD Cash K Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician2006;9:57-60. CrossrefMedlineGoogle Scholar
    • 38. Manchikanti L Manchukonda R Pampati V Damron KS Brandon DE Cash KA et alDoes random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Pain Physician2006;9:123-9. MedlineGoogle Scholar
    • 39. Chelminski PR Ives TJ Felix KM Prakken SD Miller TM Perhac JS et alA primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res2005;5:3. [PMID: 15649331] CrossrefMedlineGoogle Scholar
    • 40. Ives TJ Chelminski PR Hammett-Stabler CA Malone RM Perhac JS Potisek NM et alPredictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res2006;6:46. [PMID: 16595013] CrossrefMedlineGoogle Scholar
    • 41. Hariharan J Lamb GC Neuner JM Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med2007;22:485-90. [PMID: 17372797] CrossrefMedlineGoogle Scholar
    • 42. Burchman SL Pagel PS Implementation of a formal treatment agreement for outpatient management of chronic nonmalignant pain with opioid analgesics. J Pain Symptom Manage1995;10:556-63. [PMID: 8537698] CrossrefMedlineGoogle Scholar
    • 43. Compton PA Wu SM Schieffer B Pham Q Naliboff BD Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance. J Pain Symptom Manage2008;36:383-95. [PMID: 18508231] CrossrefMedlineGoogle Scholar
    • 44. Vaglienti RM Huber SJ Noel KR Johnstone RE Misuse of prescribed controlled substances defined by urinalysis. W V Med J2003;99:67-70. [PMID: 12874916] MedlineGoogle Scholar
    • 45. Katz NP Sherburne S Beach M Rose RJ Vielguth J Bradley J et alBehavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg2003;97:1097-102. [PMID: 14500164] CrossrefMedlineGoogle Scholar
    • 46. Kahan M Srivastava A Wilson L Gourlay D Midmer D Misuse of and dependence on opioids: study of chronic pain patients. Can Fam Physician2006;52:1081-7. [PMID: 17279218] MedlineGoogle Scholar
    • 47. Chou R Fanciullo GJ Fine PG Miaskowski C Passik SD Portenoy RK Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain2009;10:131-46. [PMID: 19187890] CrossrefMedlineGoogle Scholar
    • 48. Bosch-Capblanch X Abba K Prictor M Garner P Contracts between patients and healthcare practitioners for improving patients' adherence to treatment, prevention and health promotion activities. Cochrane Database Syst Rev2007;:CD004808. [PMID: 17443556] MedlineGoogle Scholar
    • 49. Institute for Clinical Systems Improvement. Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have an opioid agreement form and urine toxicology screen documented in the medical record (July 2008). Accessed at www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=13005&string=urine+AND+pain on 16 April 2010. Google Scholar
    • 50. Fagan MJ Chen JT Diaz JA Reinert SE Stein MD Do internal medicine residents find pain medication agreements useful? Clin J Pain2008;24:35-8. [PMID: 18180634] CrossrefMedlineGoogle Scholar
    • 51. Touchet BK Yates WR Coon KA Opioid contract use is associated with physician training level and practice specialty. J Opioid Manag2005;1:195-200. [PMID: 17315546] CrossrefMedlineGoogle Scholar
    • 52. Fleming MF Balousek SL Klessig CL Mundt MP Brown DD Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain2007;8:573-82. [PMID: 17499555] CrossrefMedlineGoogle Scholar
    • 53. Fishbain DA Cutler RB Rosomoff HL Rosomoff RS Validity of self-reported drug use in chronic pain patients. Clin J Pain1999;15:184-91. [PMID: 10524471] CrossrefMedlineGoogle Scholar
    • 54. Atluri S Sudarshan G Evaluation of abnormal urine drug screens among patients with chronic non-malignant pain treated with opioids. Pain Physician2003;6:407-9. [PMID: 16871289] MedlineGoogle Scholar
    • 55. Berndt S Maier C Schütz HW Polymedication and medication compliance in patients with chronic non-malignant pain. Pain1993;52:331-9. [PMID: 8460051] CrossrefMedlineGoogle Scholar
    • 56. Manchikanti L Damron KS Beyer CD Pampati V A comparative evaluation of illicit drug use in patients with or without controlled substance abuse in interventional pain management. Pain Physician2003;6:281-5. [PMID: 16880872] CrossrefMedlineGoogle Scholar
    • 57. Schuckman H Hazelett S Powell C Steer S A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache. Subst Use Misuse2008;43:589-95. [PMID: 18393078] CrossrefMedlineGoogle Scholar
    • 58. Sampson JM Achololnu WW Jr Reducing patient aggression and hostility in primary care with urine drug testing [Letter]. South Med J2004;97:916-7. [PMID: 15455991] CrossrefMedlineGoogle Scholar
    • 59. Gitlin MC Contracts for opioid administration for the management of chronic pain: a reappraisal [Editorial]. J Pain Symptom Manage1999;18:6-8. [PMID: 10439567] MedlineGoogle Scholar
    • 60. Heit HA Gourlay DL Urine drug testing in pain medicine. J Pain Symptom Manage2004;27:260-7. [PMID: 15010104] CrossrefMedlineGoogle Scholar
    • 61. Reisfield GM Webb FJ Bertholf RL Sloan PA Wilson GR Family physicians' proficiency in urine drug test interpretation. J Opioid Manag2007;3:333-7. [PMID: 18290585] CrossrefMedlineGoogle Scholar
    • 62. Tellioglu T The use of urine drug testing to monitor patients receiving chronic opioid therapy for persistent pain conditions. Med Health R I2008;91:279-80, 282. [PMID: 18834046] MedlineGoogle Scholar
    • 63. Fine PG Portenoy RK A Clinical Guide to Opioid Analgesia. Minneapolis: McGraw-Hill; 2004. Google Scholar
    • 64. Fishman SM Bandman TB Edwards A Borsook D The opioid contract in the management of chronic pain. J Pain Symptom Manage1999;18:27-37. [PMID: 10439570] CrossrefMedlineGoogle Scholar
    • 65. Roskos SE Keenum AJ Newman LM Wallace LS Literacy demands and formatting characteristics of opioid contracts in chronic nonmalignant pain management. J Pain2007;8:753-8. [PMID: 17382596] CrossrefMedlineGoogle Scholar
    • 66. McCleane G Smith HS Opioids for persistent noncancer pain. Anesthesiol Clin2007;25:787-807, vi-ii. [PMID: 18054145] CrossrefMedlineGoogle Scholar
    • 67. Ballantyne JC Opioids for chronic nonterminal pain. South Med J2006;99:1245-55. [PMID: 17195420] CrossrefMedlineGoogle Scholar
    • 68. Sung HE Richter L Vaughan R Johnson PB Thom B Nonmedical use of prescription opioids among teenagers in the United States: trends and correlates. J Adolesc Health2005;37:44-51. [PMID: 15963906] CrossrefMedlineGoogle Scholar
    • 69. Pergolizzi J Böger RH Budd K Dahan A Erdine S Hans G et alOpioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract2008;8:287-313. [PMID: 18503626] MedlineGoogle Scholar