Doctors lax in monitoring potentially addicting drugs, study suggests

The study, published in the March 2 online edition of the Journal of General Internal Medicine, found lax monitoring even of patients at high risk for opioid misuse, such as those with a history of drug abuse or dependence. The findings are especially concerning considering that prescription drug abuse now ranks second (after marijuana) among illicitly used drugs, with approximately 2.2 million Americans using pain relievers nonmedically for the first time in 2009, according to the National Institute on Drug Abuse (NIDA).

"Our study highlights a missed opportunity for identifying and reducing misuse of prescribed opioids in primary care settings," said lead author Joanna Starrels, M.D., M.S. , assistant professor of medicine at Einstein. "The finding that physicians did not increase precautions for patients at highest risk for opioid misuse should be a call for a standardized approach to monitoring."

The researchers studied administrative and medical records of more than 1,600 primary care patients for an average of two years while they received regular prescription opioids for chronic, non-cancer pain. They looked at whether patients received urine drug testing, were seen regularly in the office, or received multiple early opioid refills.

Only a small minority (8 percent) of patients were found to have undergone any urine drug testing. While such testing was more common in patients at higher risk for opioid misuse, the rate of testing among those high-risk patients was still low (24 percent). Only half of patients were seen regularly in the office, and patients at higher risk of opioid misuse were not seen more frequently than patients at lower risk. Although fewer than one-quarter (23 percent) of all patients received two or more early opioid refills, patients at greater risk for opioid misuse were more likely to receive multiple early refills.

"We were disturbed to find that patients with a drug use disorder were seen less frequently in the office and were prescribed more early refills than patients without these disorders," said Dr. Starrels. "We hope that these findings will call attention to this important safety concern."

Prescription drug misuse is a major public health problem. In a 2004 NIDA report , it was estimated that 48 million people over the age of 12 have taken prescription drugs for nonmedical uses in their lifetime -- which represents approximately 20 percent of the U.S. population. Opioids, central nervous system depressants and stimulants were the drugs most commonly abused.

"Most primary care physicians are attuned to these problems," said Dr. Starrels, "but they haven't put sufficient strategies in place to help reduce risks." She and her co-authors recommend that physicians adopt the following risk-reduction strategies: standardize a plan of care for all patients on long-term opioids, which includes urine drug testing; schedule regular face-to-face office visits to evaluate patients' response to opioids and evidence of misuse; and stick to a previously agreed-upon refill schedule.

The paper, "Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain," was published March 2, 2011 in the online edition of the Journal of General Internal Medicine. Co-authors include William C. Becker, M.D., of Yale University School of Medicine, New Haven, CT; Mark G. Weiner, M.D., of the University of Pennsylvania School of Medicine, Philadelphia, PA; Xuan Li, M.S., and Moonseong Heo, Ph.D., of Einstein; and Barbara J. Turner, M.D., M.S.Ed., of the University of Texas Health Science Center and University Health System, San Antonio,