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

Abstract

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.