Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain

Joanna L Starrels, William C Becker, Daniel P Alford, Alok Kapoor, Arthur Robinson Williams, Barbara J Turner
Annals of Internal Medicine 2010 June 1, 152 (11): 712-20

BACKGROUND: Experts recommend opioid treatment agreements and urine drug testing to reduce opioid analgesia misuse, but evidence of their effectiveness has not been systematically reviewed.

PURPOSE: To synthesize studies of the association of treatment agreements and urine drug testing with opioid misuse outcomes in outpatients with chronic noncancer pain.

DATA SOURCES: MEDLINE, PsycINFO, EMBASE, Cochrane Central Register of Controlled Clinical Trials (January 1966 to June 2009), reference lists, and expert contacts.

STUDY SELECTION: 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.

DATA EXTRACTION: 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.

DATA SYNTHESIS: Of 102 eligible studies, 11 met inclusion criteria; 6 were in pain clinics and 5 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 4 studies with comparison groups, opioid misuse was modestly reduced (7% to 23%) after treatment agreements with or without urine drug testing. In the other 7 studies, the proportion of patients with opioid misuse after treatment agreements, urine drug testing, or both varied widely (3% to 43%).

LIMITATIONS: Diversity of interventions and opioid misuse measures precluded meta-analysis. Most studies evaluated combinations of interventions.

CONCLUSION: 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.

PRIMARY FUNDING SOURCE: Substance Abuse and Mental Health Services Administration, National Institute on Drug Abuse, and Robert Wood Johnson Foundation.

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