Among Patients Receiving Long-term Opioid Therapy, Stimulant-positive Drug Tests Were Not Associated With Subsequent Harm

Guidelines for prescribing opioid medications for chronic pain state that non-prescribed substance use—including that of stimulants, cocaine, and methamphetamine—contribute to the risks associated with long-term opioid therapy (LTOT). This study investigated the associations between stimulant-positive urine drug tests (UDT) and subsequent (within 90 days) emergency department (ED) visits, overdose deaths, and discontinuation of LTOT among 600 patients prescribed LTOT with 1:1 matching of HIV positive and negative adults.

  • Of the 600 patients, 547 (91 percent) had at least one recorded UDT from 2012 to 2019; of these, 270 (49 percent) had at least one stimulant-positive UDT. Of 6088 UDTs recorded, 24 percent were stimulant-positive.
  • Individuals with at least one stimulant-positive UDT were more likely to have had an ED visit during the study period (28 percent versus 9 percent), but stimulant-positive UDTs were not associated with ED visits within 90 days.
  • There were 22 opioid overdose deaths during the follow-up period; none were within 90 days of a stimulant-positive UDT.
  • Stimulant-positive UDTs were associated with discontinuation of LTOT.

Comments: This study suggests that providers should not reflexively discontinue LTOT in individuals who have a UDT positive for non-prescribed stimulants. Rather, these results should prompt a discussion of stimulant use, its impact on the patient’s health, and ways in which risks can be minimized.

Darius A. Rastegar, MD

Reference: Appa A, McMahan VM, Long K, et al. Stimulant use and opioid-related harm in patients on long-term opioids for chronic pain. Drug Alcohol Depend. 2024;256:111065.

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