Adherence to Prescription Opioid Monitoring Guidelines among Residents and Attending Physicians in the Primary Care Setting

Abstract

Objective To compare adherence to opioid prescribing guidelines and potential opioid misuse in patients of resident versus attending physicians. Design Retrospective cross-sectional study. Setting Large primary care practice at a safety-net hospital in New England. Subjects Patients 18–89 years old, with at least one visit to the primary care clinic within the past year and were prescribed long-term opioid treatment for chronic non-cancer pain. Methods Data were abstracted from the EMR by a trained data analyst through a clinical data warehouse. The primary outcomes were adherence to any one of two American Pain Society Guidelines; 1) documentation of at least one opioid agreement (contract) ever, and 2) any urine drug testing in the past year; and 3) evidence of potential prescription misuse defined as ≥2 early refills. We employed logistic regression analysis to assess whether patients’ physician status predicts guideline adherence and/or potential opioid misuse. Results Similar proportions of resident and attending patients had a controlled substance agreement (45.1% of resident patients vs. 42.4% of attending patient, p=0.47) or urine drug testing (58.6% of resident patients vs. 63.6% of attending patients, p=0.16). Resident patients were more likely to have two or more early refills in the past year relative to attending patients (42.8% vs. 32.5%; p=0.004). In the adjusted regression analysis, resident patients were more likely to receive early refills (OR 1.82, 95% CI 1.26–2.62) than attending patients. Conclusions With some variability, residents and attending physicians were only partly compliant with national guidelines. Residents were more likely to manage patients with a higher likelihood of opioid misuse.

Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain

“…(1) Efforts to manage this increase in mortality have focused on modifying the prescribing practices of providers. (2) Mandated urine testing, pain agreements, and inspections of prescription drug monitoring program data have become standard practice, yet there are few data to support a link between such interventions and reduced opioid-related morbidity or mortality. In fact, while opioid analgesic deaths have recently plateaued, heroin use and overdose deaths have skyrocketed, suggesting possible unintended consequences of opioid stewardship initiatives.…”

Primary Care Providers’ Experiences with Urine Toxicology Tests to Manage Prescription Opioid Misuse and Substance use among Chronic Noncancer Pain Patients in Safety Net Health Care Settings

“…Our findings are consistent with studies that found low adherence rates for urine toxicology tests among clinicians who cared for patients at increased risk of misuse 20,38–40 and in safety net health settings. 41 …”

Factors Associated with Opioid Dose Increases: A Chart Review of Patients’ First Year on Long-Term Opioids

“…28 Similarly, only one patient between both groups had any documentation that a urine drug screen was utilized, consistent with prior work that providers infrequently order urine drug screens, though more recent studies show this may be improving. 9, 10, 29 …”

“…Little is known about how providers make decisions about opioid dosing (i.e., to continue, increase, or decrease a patient’s dose) when they write individual prescriptions. Prior studies examining risk factors for high-dose opioid use and opioid misuse have found that documentation of guideline-concordant practices for safe opioid prescribing is poor; 9, 10, 11, 12, 13 however, neither providers’ rationale for individual opioid prescriptions nor encounter-level factors associated with opioid dose increases have been previously studied.…”