Patient Opioid Agreements and Urine Drug Testing: Helpful?

opioidThe federal government’s Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning indicates that the misuse of prescription opioids continues to be a growing problem.[1] In fact, the number of emergency department visits for nonmedical use of opioid analgesics increased from 144, 600 in 2004 to 305, 900 in 2008—a 111% increase.1 There is no sign that the problem is leveling-off either. 1

Opioids must be prescribed by a health care professional; therefore, seeking out methods that will limit the non-therapeutic use of these medicines is necessary.1 Steven A. King, M.D, M.S. states that when he prescribes a patient an opioid he discusses the importance of using the medicine as prescribed.1 He also tells the patient that they should inform him if they are receiving other care or medicines for pain; if they are having problems with the medicine, such as lack of efficacy; and that they should avoid substances, legal or illegal, that may interfere with the actions of the opioid.1

However, King does not use patient opioid agreements and urine drug testing—why?1 While they may benefit some patients, there is no firm evidence that they actually reduce the likelihood that opioids will be used in unintended ways.1 In the joint guidelines for Chronic Opioid Therapy (COT) in Chronic Non-Cancer Pain, the American Pain Society and the American Academy of Pain Medicine state that “clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient expectations.”1 However, they also state that “there is insufficient evidence to guide specific recommendations on which provisions to include.”1

Conducting an extensive literature review of the value of patient opioid agreements and urine drug testing for patients with chronic pain, Starrels and colleagues found only 11 articles that met their criteria of original research that addressed the use of both for patients using opioids for at least three months.1 Of those 11 studies, six were conducted in pain clinics and five in primary care settings.1 Seven used both patient opioid agreements and urine drug tests, and one used only the latter.1 Of the studies that gave examples of the patient opioid agreements that were used, most had agreements that patients would not abuse illicit drugs or alcohol and would only receive opioid prescriptions from a single provider and pharmacy, not requesting refills before the previous prescription was completed.1

There were many inconsistencies. None of the studies used the DSM criteria for opioid abuse or dependence when identifying opioid misuse.1 Some included substance abusers, and some did not.1 The reductions found in those who used patient opioid agreements were weak.1 None of the studies were criticized with quality.1 Therefore, the studies regarding the benefits of using patient opioid agreements and urine drug tests are not evidence-based to show a need for them.1

Although they cause no harm, King believes that they limit how a physician deals with questionable behavior by patients.1 Both agreements and drug tests give health care providers a false sense of security that their use will reduce or eliminate the risk of misuse of opioids.1 As it is impossible to foresee every issue and concern that may arise and not covered by an agreement, the physician can end up in a debate with the patient about the fairness of adding new restrictions.1 While it is possible to include a statement in the agreement that the physician has the right to add restrictions to address unforeseen circumstances, it makes the agreement more of a guide.1

However, if the patient is at a high risk of medicine abuse or has a history of substance abuse, a written agreement should be strongly considered, outlining patient responsibilities, testing screenings, number and frequency of prescription refills, and reasons for which the drug therapy may be discontinued.1 Unless there is a history of substance abuse, it is often almost impossible to accurately determine the risk level for the misuse of opioids legitimately prescribed for the treatment of pain.1

[1] King, S. (2011, March 2). How Useful Are Patient Opioid Agreements and Urine Drug Testing?. Psychiatric Times. Retrieved December 2, 2013, from http://www.psychiatrictimes.com/opioid-related-disorders/how-useful-are-patient-opioid-agreements-and-urine-drug-testing

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