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Correlates of opiate misuse based on aberrant urine drug tests for patients on chronic opiate therapy in a safety-net, academic primary care clinic

Smita Bakhai, MD, MPH, FACP, Bright Thilagar, MD, Jessica L. Reynolds, PhD, Kenneth E. Leonard, PhD


Objective: Determine correlates of opiate misuse based on urine drug test (UDT) among patients on chronic opiate therapy (COT) for chronic noncancer pain.

Design: A cross-sectional study.

Setting: Urban, academic clinic.

Participants: UDT performed in 206 patients on COT for at least 3 months duration within a one-year period. Patients were classified based on UDT results: (1) Appearance of Opiate Adherence: Positive UDT for prescribed opiate and negative for illicit drugs and nonprescribed control substances; (2) Opiate Misuse; Overt nonadherence: (a) Positive UDT for illicit drugs and/or nonprescribed controlled substances AND positive or negative for prescribed opiates (b) Overdose; (3) Possible opiate nonadherence: Negative for prescribed opiates and negative for illicit and nonprescribed controlled substances.

Interventions: None.

Main outcome measures: UDT results, patient demographics, medical history, healthcare adherence, and utilization measures.

Results: Of the 206 records analyzed, 80 (38 percent) had appearance of opiate adherence, 91 (44 percent) had misuse, and 35 (17 percent) had possible opiate nonadherence. Analysis was performed comparing misuse and appearance of opiate adherence groups. In bivariate analyses, history of smoking (OR 3.90, 95% CI 1.69-9.03), substance use (OR 7.02, 95% CI 2.56-19.20), missed medical appointments (OR 2.85, 95% CI 1.44-5.63), and nonadherence to other medications correlated with misuse group (OR 18.86, 95% CI 8.73-40.74). In logistic regression, only substance use history (OR 4.32, 95% CI 1.27-14.64) and nonadherence with nonopiate medications (OR 13.22, 95% CI 5.81-30.10) correlated with misuse.

Conclusions: Medication nonadherence and missed appointments for other chronic conditions were significant correlates of opiate misuse.


prescription opioid misuse, nonadherence, urine drug test, primary care, substance use disorder, chronic noncancer pain

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Administration USDoJDE: National drug threat assessment summary. Available at Accessed January 20, 2017.

Medicine ASoA: Opioid addict ion 2016 Facts & Figures. Available at Accessed January 26, 2017.

Brady KT, McCauley JL, Back SE: Prescription opioid misuse, abuse, and treatment in the United States: An update. Am J Psychiatry. 2016; 173: 18-26.

Frieden TR, Houry D: Reducing the risks of relief — The CDC opioid-prescribing guideline. New Engl J Med. 2016; 374: 1501-1504.

Center for Behavorial health statistics and quality behavioral health: Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Available at http://wwwsamhsagov/data/. 2015. Accessed January 20, 2017.

Hedegaard H, Chen LH, Warner M: Drug-poisoning deaths involving heroin: United States, 2000-2013. NCHS Data Brief. 2015; 190: 1-8.

Kuehn BM: SAMHSA: Pain medication abuse: A common path to heroin experts say this pattern likely driving heroin resurgence. JAMA. 2013; 310: 1433-1434.

Manchikanti L, Helm S, 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain Physician. 2012; 15: ES9-ES38.

Breuer B, Cruciani R, Portenoy RK: Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. Nat Survey Pain Manage Clinicians. 2010; 103: 738-747.

Calcaterra SL, Yamashita TE, Min SJ, et al.: Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016; 31: 478-485.

Tobin DG, Andrews R, Becker WC: Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleve Clin J Med. 2016; 83: 207-215.

Compton P: The role of urine toxicology in chronic opioid analgesic therapy. Pain Manag Nurs. 2007; 8: 166-172.

Ceasar R, Chang J, Zamora K, et al.: 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. Subst Abus. 2016; 37: 154-160.

McCarberg BH: A critical assessment of opioid treatment adherence using urine drug testing in chronic pain management. Postgrad Med. 2011; 123: 124-131.

CDC: CDC guideline for prescribing opioids for chronic pain — United States. MMWR. 2016; 65(1): 1-49.

Lasser KE, Shanahan C, Parker V, et al.: A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol. J Subst Abuse Treat. 2016; 60: 101-109.

Khalid L, Liebschutz JM, Xuan Z, et al.: Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med. 2015; 16: 480-487.

Turner JA, Saunders K, Shortreed SM, et al.: Chronic opioid therapy urine drug testing in primary care: Prevalence and predictors of aberrant results. J Gen Intern Med. 2014; 29: 1663-1671.

Morasco BJ, Peters D, Krebs EE, et al.: Predictors of urine drug testing for patients with chronic pain: Results from a national cohort of U.S. veterans. Subst Abuse. 2016; 37: 82-87.

Bauer SR, Hitchner L, Harrison H, et al.: Predictors of higher-risk chronic opioid prescriptions in an academic primary care setting. Subst Abuse. 2016; 37: 110-117.

Chiovaro J: Capsule commentary on Turner et al., chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results. J Gen Intern Med. 2015; 30: 241.

Sehgal N, Manchikanti L, Smith HS: Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Phys. 2012; 15: ES67-ES92.

Manchikanti L, Giordan J, Boswell MV, et al.: Pyschological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. J Opioid Manage. 2007; 3: 89-100.

Ives TJ, Chelminski PR, Hammett-Stabler CA, et al.: Predictors of opioid misuse in patients with chronic pain: A prospective cohort study. BMC Health Serv Res. 2006; 6: 46.

Becker WC, Merlin JS, Manhapra A, et al.: Management of patients with issues related to opioid safety, efficacy and/or misuse: A case series from an integrated, interdisciplinary clinic. Addict Sci Clin Pract. 2016; 11: 3.

Boscarino JA, Rukstalis M, Hoffman SN, et al.: Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010; 105: 1776-1782.

Manchikanti L, Hammer MJ, Benyamin RM, et al.: Physician Quality Reporting System (PQRS) for Interventional Pain Management Practices: Challenges and Opportunities. Pain Phys. 2016; 19: E15-E32.

Manchikanti L, Manchikanti KN, Pampati V, et al.: Prevalence of side effects of prolonged low or moderate dose opioid therapy with concomitant benzodiazepine and/or antidepressant therapy in chronic non-cancer pain. Pain Phys. 2009; 12: 259-267.

Manchikanti L, Damron K, Pampati V, et al.: Prevalence of illicit drug use among individuals with chronic pain in the commonwealth of Kentucky: An evaluation of patterns and trends. JKY Med Assoc. 2005; 103: 55-62.

Manchikanti L, Pampati V, Damron KS, et al.: Prevalence of illicit drug use in patients without controlled substance abuse in interventional pain management. Pain Phys. 2003; 6: 173-178.

Manchikanti L, Pampati V, Falco FJ, et al.: An updated assessment of utilization of interventional pain management techniques in the medicare population: 2000 – 2013. Pain Phys. 2015; 18: E115-E127.

Brown J, Setnik B, Lee K, et al.: Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011; 7:467-483.

Chelminski PR, Ives TJ, Felix KM, et al.: A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005; 5: 3.

Codeine and Morphine Pathway, Pharmacokinetics. Available at Accessed January 20, 2017.

Available at Accessed October 19, 2017.

Starrels JL, Becker WC, Alford DP, et al.: Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Int Med. 2010; 152: 712-720.

Manchikanti L, Malla Y, Wargo BW, et al.: Protocol for accuracy of point of care (POC) or in-office urine drug testing (Immunoassay) in chronic pain patients: A prospective analysis of immunoassay and liquid chromatography tandem mass spectrometry (LC/MS/MS). Pain Phys. 2010; 13: E1-E22.

Standridge JB, Adams SM, Zotos AP: Urine drug screening: A valuable office procedure. Am Family Phys. 2010; 81: 635-640.

Christo PJ, Manchikanti L, Ruan X, et al.: Urine drug testing in chronic pain. Pain Phys. 2011; 14: 123-143.

Manchikanti L, Malla Y, Wargo BW, et al.: Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients. Pain Phys. 2011; 14: 175-197.

Mayo Clinic Medical Laboratories; Approximate detection times. Available at Accessed January 26, 2017.

Reid MC, Henderson CR, Jr, Papaleontiou M, et al.: Characteristics of older adults receiving opioids in primary care: Treatment duration and outcomes. Pain Med. 2010; 11: 1063-1071.

Fishbain DA, Cole B, Lewis J, et al.: What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008; 9: 444-459.

Meltzer EC, Rybin D, Saitz R, et al.: Identifying prescription opioid use disorder in primary care: Diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain. 2011; 152: 397-402.

Manchikanti L, Pampati V, Damron KS, et al.: Prevalence of prescription drug abuse and dependency in patients with chronic pain in Western Kentucky. J Ky Med Assoc. 2003; 101: 511-517.

Manchikanti L, Damron KS, McManus CD, et al.: Patterns of illicit drug use and opioid abuse in patients with chronic pain at initial evaluation: A prospective, observational study. Pain Phys. 2004; 7: 431-437.

24 Legal Medical Marijuana States and DC. Available at Accessed July 28, 2016.

Manchikanti L, Cash KA, Damron KS, et al.: Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables. Pain Phys. 2006; 9: 215-225.

Manchikanti L, Falco FJ, Hirsch JA: Opioid prescribing. Ann Intern Med. 2014; 160: 737.

Leider H, Dhaliwal J, Davis E, et al.: Healthcare costs and nonadherence among chronic opioid users. Am J Manag Care. 2011; 17: 32-40.

Ries R, Krupski A, West II, et al.: Correlates of opioid use in adults with self-reported drug use recruited from public safety-net primary care clinics. J Addict Med. 2015; 9: 417-426.



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