Open Access Open Access  Restricted Access Subscription or Fee Access

Patient aberrant drug taking behaviors in a large family medicine residency program: A retrospective chart review of screening practices, incidence, and predictors

Matthew Lewis, PharmD, Christopher M. Herndon, PharmD, BCPS, CPE, John T. Chibnall, PhD


Introduction: Potentially aberrant drug-taking behaviors (pADTB) are described as any departure from strict adherence to prescribed use of medications for their intended indication. There are several validated instruments, processes, and databases available to assist the clinician in screening and stratifying risk for patients in which controlled substances are being prescribed or considered. Actual utilization of these tools in nonspecialist healthcare settings is largely unknown. The primary objective of this retrospective chart review was to describe utilization patterns of these common tools within a 56 physician family medicine training program. Secondary objectives included identification of site-specific predictors of pADTB and correlation of prescribing patterns with documented aberrant behaviors.

Methods: A total of 202 chronic pain patients were identified for inclusion based on prior 12-month prescription and refill records within the electronic health record (EHR) from March 2008 through March 2009. Each patient included had at least one opioid for 30 days within the study period and had chronic pain symptoms for at least 90 days. Each chart was reviewed for predefined pADTB, controlled substance refill request, prescription drug monitoring profile, and post hoc investigator completion of the Opioid Risk Tool Clinician Form. Descriptive statistics and regression analysis was used to report results.

Results: Clinician documentation of risk-screening tool use of any type was limited to one patient of the 202 records reviewed. Within this sample, 203 unique pADTB were documented in the EHR records of 89 (44.1 percent) patients. Patients prescribed morphine or tramadol appeared to exhibit less use of multiple prescribers and multiple pharmacies while an association between this behavior and two or more concurrent opioid prescriptions became apparent. Those taking fentanyl or morphine exhibited unsanctioned dose escalations more frequently.

Conclusions: These results suggest that routine evaluation of risk for abuse or misuse of opioid analgesics occurs infrequently in a large family medicine training program. pADTB exhibited by patients using opioids for chronic pain syndromes in this sample were consistent with those reported in other similar settings. Policies and procedures in primary care settings for improved risk evaluation and ongoing monitoring of chronic opioid therapy is needed.


misuse, abuse, aberrant behaviors, opioid, opiate, chronic pain, risk mitigation, predictors

Full Text:



Anon.: IOM calls for transformation of attitudes toward pain and its prevention and management. J Pain Palliat Care Pharmacother. 2012; 26: 40 - 43.

Victor TW, Alvarez NA, Gould E: Opioid prescribing practices in chronic pain management: Guidelines do not sufficiently influence clinical practice. J Pain. 2009; 10: 1051 - 1057.

Ertischek MD, Schnoll SH, Sembower MA: Explanations for increased prescription drug abuse. Health Affairs. 2011; 30: 1808.

Administration SAaMHS: Results from the 2012 National Survey on Drug Use and Health: Summary of national findings. HHS Publication No. (SMA) 13-4795 ed. Rockville, MD: SAaMHS, 2013.

Administration SAaMHS: Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. Rockville, MD: SAaMHS, 2013.

IMS: IMS Top-Line Market Data. U.S. Dispensed Prescription Information: Top 25 medicines by Dispensed Prescriptions U.S. 2012. Available at Accessed March 11, 2014.

AAFP: AAFP position paper opposes mandated CME, other barriers for prescribers of opioids. Ann Fam Med. 2012; 10: 474 - 475.

Cepeda MS, Fife D, Berlin JA, et al.: Characteristics of prescribers whose patients shop for opioids: Results from a cohort study. J Opioid Manag. 2012; 8: 285 - 291.

Slevin KA, Ashburn MA: Primary care physician opinion survey on FDA opioid risk evaluation and mitigation strategies. J Opioid Manag. 2011; 7: 109 - 115.

Gudin J: Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics: Considerations for palliative care practice. J Pain Palliat Care Pharmacother. 2012; 26: 136 - 143.

Nelson LS, Perrone J: Curbing the opioid epidemic in the United States: The risk evaluation and mitigation strategy (REMS). J Am Med Assoc. 2012; 308: 457 - 458.

Fleming MF, Davis J, Passik SD: Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. Pain Med. 2008; 9: 1098 - 1106.

Bohn TM, Levy LB, Celin S, et al.: Screening for abuse risk in pain patients. Adv Psychosom Med. 2011; 30: 113 - 124.

Moore TM, Jones T, Browder JH, et al.: A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009; 10: 1426 - 1433.

Passik SD, Kirsh KL: An opioid screening instrument: long-term evaluation of the utility of the pain medication questionnaire by Holmes et al. Pain Pract. 2006; 6: 69 - 71.

Lewis-Idema D, Chu R, Hughes R, et al.: FQHC (Federally Qualified Health Center): Harnessing the incentives of cost reimbursement. J Am Care Manage. 1998; 21: 58 - 73; discussion 4-5.

Webster LR, Webster RM: Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6: 432 - 442.

Brennan MJ: DIRE: A tool to assess risks of maintaining opioid treatment. J Pain. 2007; 8: 185.

Koyyalagunta D, Bruera E, Aigner C, et al.: Risk stratification of opioid misuse among patients with cancer pain using the SOAPP-SF. Pain Med. 2013; 14: 667 - 675.

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.



  • There are currently no refbacks.