Heit HA, Gourlay DG. Annals Int Med. 2010;152(11):747-748.
Abstract
Stories about the tragic consequences of prescription drug misuse increasingly populate the media. In 2007, the Substance Abuse and Mental Health Services Administration revealed that in the previous year, illicit use of prescription opioids exceeded that of marijuana among persons 12 years or older. Clearly, times are changing, and abuse of prescription drugs is something clinicians must actively address. In this issue, Starrels and colleagues report a review of the evidence about the effectiveness of 2 common clinical tools to reduce opioid misuse in patients with chronic pain: opioid treatment agreements and urine drug testing. We commend the authors’ efforts to better understand the difficult, growing, and too often ignored challenge of prescription drug misuse. Unfortunately, this review documents how much more we need to know to successfully tackle this vexing issue.
We draw the following conclusions after considering Starrels and colleagues’ work. First, despite the enthusiastic endorsement of treatment agreements and urine drug testing by some regulators, educators, and clinicians, there remains little evidence documenting their effectiveness in preventing or treating drug misuse or addiction. Second, the lack of clear definitions of these interventions makes comparisons of the few studies that do exist difficult. Finally, clinicians should not assume that there is no “down side” to the overzealous use of either of these tools. As Starrels and colleagues state, the potential harm from using these strategies include patients forgoing pain treatment because of undue stigma and clinicians under- treating pain because of the perceived burden of opioid risk management. Overly restrictive treatment agreements can make it difficult for any patient to stay within accepted boundaries, resulting in inevitable departures from treatment adherence. Similarly, overreliance on urine drug testing can introduce mistrust into the therapeutic relationship. Both interventions demand resources and, if not effective, might divert resources from more beneficial clinical services.
Discussion Points According to the Authors:
- A rapid and dramatic increase in prescription drug abuse has led to many seeking a potential solution to this growing public health problem.
- There is a need for consistency in definitions associated with addiction, abuse and misuse, as well as the content and utilization of risk minimization strategies and tools.
- There is also a great need for further research, without which, there is a real risk that risk tools may be mistakenly dismissed as ineffective or, perhaps worse, given disproportionate value as a measure of quality care.
