Doctors lax in monitoring potentially addicting drugs

Few primary care physicians pay adequate attention to patients taking prescription opioid drugs — despite the potential for abuse, addiction and overdose, according to a new study by researchers at Albert Einstein College of Medicine of Yeshiva University.

The study, published in the March 2 online edition of the Journal of General Internal Medicine, found lax monitoring even of patients at high risk for opioid misuse, such as those with a history of drug abuse or dependence. The findings are especially concerning considering that prescription drug abuse now ranks second (after marijuana) among illicitly used drugs, with approximately 2.2 million Americans using pain relievers nonmedically for the first time in 2009, according to the National Institute on Drug Abuse (NIDA).

“Our study highlights a missed opportunity for identifying and reducing misuse of prescribed opioids in primary care settings,” said lead author Joanna Starrels, M.D., M.S. , assistant professor of medicine at Einstein. “The finding that physicians did not increase precautions for patients at highest risk for opioid misuse should be a call for a standardized approach to monitoring.”

The researchers studied administrative and medical records of more than 1,600 primary care patients for an average of two years while they received regular prescription opioids for chronic, non-cancer pain. They looked at whether patients received urine drug testing, were seen regularly in the office, or received multiple early opioid refills.

Only a small minority (8 percent) of patients were found to have undergone any urine drug testing. While such testing was more common in patients at higher risk for opioid misuse, the rate of testing among those high-risk patients was still low (24 percent). Only half of patients were seen regularly in the office, and patients at higher risk of opioid misuse were not seen more frequently than patients at lower risk. Although fewer than one-quarter (23 percent) of all patients received two or more early opioid refills, patients at greater risk for opioid misuse were more likely to receive multiple early refills.

“We were disturbed to find that patients with a drug use disorder were seen less frequently in the office and were prescribed more early refills than patients without these disorders,” said Dr. Starrels. “We hope that these findings will call attention to this important safety concern.”

Prescription drug misuse is a major public health problem. In a 2004 NIDA report , it was estimated that 48 million people over the age of 12 have taken prescription drugs for nonmedical uses in their lifetime – which represents approximately 20 percent of the U.S. population. Opioids, central nervous system depressants and stimulants were the drugs most commonly abused.

“Most primary care physicians are attuned to these problems,” said Dr. Starrels, “but they haven't put sufficient strategies in place to help reduce risks.” She and her co-authors recommend that physicians adopt the following risk-reduction strategies: standardize a plan of care for all patients on long-term opioids, which includes urine drug testing; schedule regular face-to-face office visits to evaluate patients' response to opioids and evidence of misuse; and stick to a previously agreed-upon refill schedule.

The paper, “Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain,” was published March 2, 2011 in the online edition of the Journal of General Internal Medicine. Co-authors include William C. Becker, M.D., of Yale University School of Medicine, New Haven, CT; Mark G. Weiner, M.D., of the University of Pennsylvania School of Medicine, Philadelphia, PA; Xuan Li, M.S., and Moonseong Heo, Ph.D., of Einstein; and Barbara J. Turner, M.D., M.S.Ed., of the University of Texas Health Science Center and University Health System, San Antonio, TX.

About Albert Einstein College of Medicine of Yeshiva University

Albert Einstein College of Medicine of Yeshiva University is one of the nation's premier centers for research, medical education and clinical investigation. During the 2009-2010 academic year, Einstein is home to 722 M.D. students, 243 Ph.D.students, 128 students in the combined M.D./Ph.D. program, and approximately 350 postdoctoral research fellows. The College of Medicine has 2,775 fulltime faculty members located on the main campus and at its clinical affiliates. In 2009, Einstein received more than $155 million in support from the NIH. This includes the funding of major research centers at Einstein in diabetes, cancer, liver disease, and AIDS. Other areas where the College of Medicine is concentrating its efforts include developmental brain research, neuroscience, cardiac disease, and initiatives to reduce and eliminate ethnic and racial health disparities. Through its extensive affiliation network involving five medical centers in the Bronx, Manhattan and Long Island – which includes Montefiore Medical Center, The University Hospital and Academic Medical Center for Einstein – the College of Medicine runs one of the largest post-graduate medical training programs in the United States, offering approximately 150 residency programs to more than 2,500 physicians in training. For more information, please visit www.einstein.yu.edu