Demographic Patterns Associated With Compliance in Pain Contract Patients: A Residency Clinic Experience.

To the Editor:

Chronic pain (CP) management is a challenging task for primary care physicians, with at least 116 million adult Americans having CP associated with decreased quality of life. In 2010, around 9% of the US population older than 12 years were reported to be illicit drug users, with nonmedical use of prescription drugs being the second most commonly used drug. Primary care physicians, however, are often concerned when prescribing opioids about abuse, misuse, addiction, and potential prosecution and disciplinary actions. In 2012, the American Society of Interventional Pain Physicians (ASIPP) recommended comprehensive assessment and screening for opioid use and implementation of prescription drug monitoring programs (PDMPs) and urine drug screening (UDS) to decrease prescription drug abuse when patients are receiving CP management therapy. The ASIPP also recommended that “a robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion.” Similar use of PDMPs and UDS with annual urine drug testing has been recommended by the Centers for Disease Control and Prevention when prescribing opioids for CP.

In 2007, the internal medicine residency clinic at Western Michigan University Homer Stryker M.D. School of Medicine initiated a policy for opioid prescription for CP management requiring pain contracts, PDMPs via the Michigan Automated Prescription System (MAPS), and random UDS. We report the results of a study undertaken to analyze the experience of the clinic with pain management policy and to identify demographic parameters associated with violation of pain contracts.

Patients and Methods

We conducted a retrospective cohort study of all adult patients who participated in a program of long-term opioid therapy (defined as longer than 4 weeks) and a pain contract at our residency clinic between March 1, 2007, and June 30, 2013. Patients were identified as currently compliant with the pain contract (group 1), those weaned from opioid analgesics (group 2), and those who violated the pain contract (group 3). Intergroup comparison was done to determine high-risk demographic parameters associated with violation of pain contracts. Statistical analysis was performed using the χ2 test and SPSS statistical software, version 17.0 for Windows (SPSS Inc).

Results

Of the 325 patients who initiated the program of long-term opioid therapy and a pain contract, 106 (32.6%) were compliant with the contract (group 1), 47 (14.5%) were successfully weaned from opioids (group 2), and 172 (52.9%) violated the pain contract (group 3) (Table). Patients who violated the contract were younger (mean ± SD age, 49.5±11.2 years) compared with patients in group 2 (56.8±14.7 years) and group 1 (56.3±13.5 years) (P<.001). Patients who violated the contract were more likely to be current smokers (P<.001) and have an underlying psychiatric disorder (P=.023). Female sex was associated with successful weaning from opiates (P=.032). There was no significant difference in the 3 groups with respect to underlying diagnosis (P=.44), employment (P=.35), marital status (P=.56), or ethnicity (P=.13). For the 106 patients compliant with the pain contract, 104 patients (98.1%) had random UDS, and all 106 patients had MAPS review with 104 patients (98.1%) having their last MAPS review within the preceding 12 months.

Table

Distribution of Demographic Parameters in the 325 Study Patientsa,b

Variable	Patients maintained on opioid analgesics (n=106)	Patient weaned from opioid analgesics (n=47)	Patients violating the pain contract (n=172)	P value
Age (y)				<.001
Mean ± SD	56.3±13.5	56.8±14.7	49.5±11.2
Range	20-93	24-87	18-88
Sex				.032
Male	52 (49.1)	15 (31.9)	92 (53.5)
Female	54 (50.9)	32 (68.1)	80 (46.5)
Ethnicity				.13
African American	26 (24.5)	5 (10.6)	23 (13.4)
White	73 (68.87)	37 (78.7)	62 (36.0)
Unknown	5 (4.72)	0	85 (49.4)
Other	2 (1.89)	5 (10.6)	2 (1.2)
Relationship status				.56
Single	43 (40.6)	23 (48.9)	76 (44.2)
Married	35 (33.0)	11 (23.4)	43 (25.0)
Other (divorced, widowed, legally separated)	28 (26.4)	12 (25.5)	33 (19.2)
Unknown	0	1 (2.1)	20 (11.6)
Employment status				.35
Employed	8 (7.5)	2 (4.2)	17 (9.9)
Unemployed	88 (83.0)	40 (85.1)	128 (74.4)
Unknown	10 (9.4)	5 (10.6)	27 (15.7)
Smoking				<.001
Current	44 (41.5)	17 (36.2)	95 (55.2)
Former	33 (31.1)	15 (31.9)	16 (9.3)
Never	27 (25.5)	11 (23.4)	16 (9.3)
Unknown	2 (1.9)	4 (8.5)	45 (26.2)
Diagnosis				.44
Abdominal pain	3 (2.8)	1 (2.1)	5 (2.9)
Back pain	63 (59.4)	23 (48.9)	111 (64.5)
Cancer	6 (5.7)	3 (6.4)	5 (2.9)
CPS/fibromyalgia	5 (4.7)	2 (4.2)	4 (2.3)
Degenerative joint disease	15 (14.2)	6 (12.8)	25 (14.5)
Miscellaneous	14 (13.2)	12 (25.5)	22 (12.8)
Presence of psychiatric disorder	39 (36.8)	17 (36.2)	89 (51.7)	.023

CPS = chronic pain syndrome.

Data are presented as No. (percentage) of patients unless indicated otherwise. Percentages may not total 100 because of rounding.

Discussion

Our study indicated that a significant proportion of patients violated their pain contract. Younger age, associated psychiatric disorders, and current smoking were associated with violation of the pain contract. Previously, Chakrabortty et al reported middle age, obesity, and unmarried males to be associated with a breach in the narcotic use contract. Our study also highlights the high compliance of our residency clinic with ASIPP/Centers for Disease Control and Prevention guidelines. Although our study is limited because it is a single-center experience and a retrospective review, it highlights the high rate of violations/noncompliance among patients despite the use of structured guidelines and points toward the unmet need for development of alternative strategies for safe prescription of opioid analgesics.