Clinical Crossroads
Clinician's Corner
March 6, 2013

Chronic Back Pain With Possible Prescription Opioid Misuse

Author Affiliations

Clinical Crossroads Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.

Author Affiliation: Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.

JAMA. 2013;309(9):919-925. doi:10.1001/jama.2013.522

Importance Data on the effectiveness and safety of long-term opioid therapy for chronic pain are limited. Opioid adherence monitoring includes urine drug testing. Determining whether a patient's opioid prescription should be discontinued after an unexpected urine test result can be clinically complex.

Objective To review safe opioid prescribing practices and appropriate interpretation and management of unexpected urine drug test results.

Evidence Review Systematic reviews of the effectiveness and safety of long-term opioid therapy for chronic noncancer pain. Clinical management recommendations are derived from clinical guidelines generated by several professional medical organizations including the American Pain Society, the American Academy of Pain Medicine, and the Federation of State Medical Boards

Findings Informed consent and patient-prescriber agreements are important strategies to ensure that patients understand treatment goals and potential opioid risks. Monitoring for benefit and opioid misuse is accomplished by having frequent face-to-face assessments, performing urine drug tests, monitoring pill counts, and reviewing prescription drug monitoring program data, when available.

Conclusions and Relevance The underlying causes for worrisome behaviors such as urine drug test results that are negative for the prescribed opioid should be fully investigated. Subsequent opioid prescriptions should be based on the revised risk and benefit assessment.