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Over the last twenty years, opioid analgesics have been prescribed with greater frequency to the chronic noncancer pain population. In fact, opioid pain relief accounts for a huge percentage of prescriptions written in this country every year. Unfortunately, there have also been increasing incidences of drug abuse, addiction, and overdose.
In the hope that there might be some positive effect against these ugly societal side effects of prescription opioids, many medical societies have recommended written opioid treatment agreements and urine drug testing for chronic pain patients on chronic opioid pain relievers. However, studies of the primary care management of patients on long-term opioids have found that only 23% to 44% of physicians were using treatment agreements; and only 8% to 30% were obtaining urine drug screening tests. An article in the June 1, 2010 issue of "Annals of Internal Medicine" attempted to discover the reason for this disconnect between expert recommendations and follow-through rates in the primary care setting, where much of chronic opioid prescribing occurs.
The authors of this review examined published observational studies of treatment contracts and urine drug testing. They found that opioid misuse endpoints varied widely; and in fact, none addressed the most important from a medical and public health perspective: abuse, dependence, overdose and death. Additionally, many of the studies published examine chronic pain clinic settings, not the primary care setting.
That being said, the authors found limited evidence for the effectiveness of opioid treatment agreements. In contrast, there is evidence that treatment contracts can be helpful in a patient's battle with hypertension and obesity. So, does the treating primary care provider simply throw his or her hands into the air, and give up on obtaining such agreements and urine tests? Well, maybe not, as they may serve a purpose, although perhaps self-serving, for the following reasons:
1. Primary care providers do find that treatment agreements convey a sense of control in their dealings with the chronic pain patient.
2. There is evidence showing such agreements are associated with less visits to emergency departments for refills of opioid prescriptions.
3. Urine drug testing is important in testing for nonprescribed drugs.
4. Urine drug testing may also contribute to that sense of control alluded to above.
So, whether to contract with and test patients on chronic opioid medications remains a matter of choice, for now. However, with addiction, overdose and death secondary to these drugs on the rise, there needs to be more research done in the monitoring realm, and of course in the efficacy realm---are these drugs even working for many with chronic pain? At the same time, no one wishes to see patients and their physicians choosing to avoid a treatment because the monitoring is indeed so burdensome.
The challenges of the treatment of chronic pain should not exceed the pain of chronic pain.
