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.
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Author, Article, and Disclosure Information
From Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York; Yale University School of Medicine, New Haven, Connecticut; Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts; and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Preliminary results of this study were presented at the 32nd annual meeting of the Society of General Internal Medicine, Miami Beach, Florida, 13–16 May 2009.
Grant Support: Through the Program of Research Integrating Substance Use Issues into Mainstream Health Care, funded by the Robert Wood Johnson Foundation, the National Institute on Drug Abuse, and the Substance Abuse and Mental Health Services Administration. Dr. Starrels was supported in part by the Robert Wood Johnson Foundation Clinical Scholars Program.
Acknowledgment: The authors thank Karen Lillie, Carlos Rodriguez, and Moonseong Heo for contributing to the literature search and the Montefiore Division of General Internal Medicine Substance Abuse Research Group.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2037.
Corresponding Author: Barbara J. Turner, MD, MSEd, Division of General Internal Medicine, University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19134; e-mail, [email protected]
Current Author Addresses: Dr. Starrels: Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467.
Dr. Becker: Section of General Internal Medicine, Yale University School of Medicine, 367 Cedar Street, PO Box 208093, New Haven, CT 06520-8093.
Dr. Alford: Section of General Internal Medicine, Clinical Addiction, Research and Education Unit, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118.
Dr. Kapoor: Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118.
Mr. Williams: 4229 Regent Square, Philadelphia, PA 19104.
Dr. Turner: Division of General Internal Medicine, University of Pennsylvania School of Medicine, 1123 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19134.
Author Contributions: Conception and design: J.L. Starrels, W.C. Becker, D.P. Alford, A. Kapoor.
Analysis and interpretation of the data: J.L. Starrels, W.C. Becker, D.P. Alford, A. Kapoor, A.R. Williams, B.J. Turner.
Drafting of the article: J.L. Starrels, D.P. Alford, A. Kapoor, A.R. Williams, B.J. Turner.
Critical revision of the article for important intellectual content: J.L. Starrels, W.C. Becker, D.P. Alford, A. Kapoor, B.J. Turner.
Final approval of the article: J.L. Starrels, W.C. Becker, D.P. Alford, A.R. Williams, B.J. Turner.
Statistical expertise: J.L. Starrels, W.C. Becker.
Obtaining of funding: B.J. Turner.
Administrative, technical, or logistic support: A.R. Williams, B.J. Turner.
Collection and assembly of data: J.L. Starrels, W.C. Becker, D.P. Alford, A.R. Williams, B.J. Turner.
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