Systematic Review

This article studies the misuse of opioid analgesia for outpatients with chronic, noncancer pain. The authors recommend that an opioid treatment agreement and urine drug testing may reduce opioid analgesia misuse, although available evidence of their effectiveness has not been systematically reviewed.

Data sources for this study included MEDLINE, PsychINFO, EMBASE, Cochrane Central Register of Controlled Clinical Trials (January 1966 to June 2009), in addition to various reference lists and expert contacts. Original research addressing opioid medications, chronic pain, and treatment agreements or urine drug testing, with a sample size of 50 participants or more and published in English, Spanish, or French, were reviewed. Two investigators independently identified eligible studies, extracted data and assessed study quality. The outcome of opioid misuse was defined as drug abuse, drug misuse, aberrant drug-related behavior, diversion, or addiction.

Of 102 eligible studies, 11 met inclusion criteria; six were in pain clinics and five were in primary care settings. Four primary care studies examined multicomponent strategies that included interdisciplinary support. All studies were observational and rated as poor to fair quality. In four studies with comparison groups, opioid misuse was modestly reduced (7% to 23%) after treatment agreements with or without urine drug testing. In the other seven studies, the proportion of patients with opioid misuse after treatment agreements, urine drug testing, or both varied widely (3% to 43%).

A few limitations of the study that were identified included diversity of interventions and opioid misuse measures precluded meta-analysis. Most studies evaluated combinations of interventions.

The study revealed that relatively weak evidence supports the effectiveness of opioid treatment agreements and urine drug testing in reducing opioid misuse by patients with chronic pain. Further research on effective ways to monitor and reduce opioid misuse is needed, especially in primary care settings.