title: Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain.
abstract: 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.
  
  
  METHODS
  Retrospective cohort using electronic medical records.
  
  
  METHODS
  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.
  
  
  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).
  
  
  CONCLUSIONS
  Primary care physicians' adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.
authors.affiliation: Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467, USA. jostarre@montefiore.org
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Starrels
authors.forename: William C
authors.initials: WC
authors.lastname: Becker
authors.forename: Mark G
authors.initials: MG
authors.lastname: Weiner
authors.forename: Xuan
authors.initials: X
authors.lastname: Li
authors.forename: Moonseong
authors.initials: M
authors.lastname: Heo
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: Turner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000627:therapeutic use* / Q000652:urine; D059350:Chronic Pain / Q000188:drug therapy* / Q000453:epidemiology / Q000652:urine; D015331:Cohort Studies; D004353:Drug Evaluation, Preclinical / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D012189:Retrospective Studies; D012307:Risk Factors; D040242:Risk Reduction Behavior
chemical_list: D000701:Analgesics, Opioid