Treatment Agreements and Urine Drug Testing to Reduce Opioid Misuse in Patients with Chronic Pain

Joanna Starrels, MD, MS

Opioid misuse and the associated public health consequences have increased with the recent expansion of opioid prescribing for chronic pain. Various risk reduction strategies have been proposed to mitigate these risks, including opioid treatment agreements and urine drug testing. There is a dearth of evidence, however, on the effectiveness of these approaches. Starrels et al undertook a systematic review to synthesize existing evidence on the effects of treatment agreements and urine drug testing on opioid misuse outcomes—ie, drug abuse/misuse, aberrant drug-related behavior, diversion, addiction—in outpatients with chronic noncancer pain. Original studies with 50 participants or more were identified. Among 102 eligible studies, 11 met the inclusion criteria. All of these studies were observational and of poor to fair quality. A modest reduction in opioid misuse was observed in four studies following treatment agreements with or without urine drug testing. In the remaining studies, the results varied widely. Based on this review, it is evident that further research is needed on strategies to reduce opioid misuse.

References

Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712-720.
Chou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10:131-146.
Atluri S, Sudarshan G. Evaluation of abnormal urine drug screens among patients with chronic non-malignant pain treated with opioids. Pain Physician. 2003;6:407-409.
Fishman SM, Mahajan G, Jung SW, Wilsey BL. The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract. J Pain Symptom Manage. 2002;24:335-344.

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