This study assessed the impact of a multi-faceted risk reduction initiative for patients on opioid therapy.1 It focused on urine drug screening (UDS), and noted that although the initiative increased UDS (from 7 to 50 %), that rate was well below the initiative’s target. Moreover, there was no commensurate impact on the rate of abnormalities identified, such as marijuana or illicit drugs.

Opioid agreements (between prescribing physician and patient) that incorporate random UDS have been touted as an important strategy in the management of patients with chronic noncancer pain.2 This practice is more prevalent in pain medicine than in primary care.3 These results could have been impacted by confounding factors in Washington, such as the legality of medicinal marijuana in Washington and the potential impact of the Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain, which has been criticized for its potentially deleterious effect on physicians’ willingness to provide opioid therapy for patients with chronic pain.4

There is a need for further research on, among other aspects of pain management, the effectiveness of separate opioid contracts (in contradistinction to a detailed informed consent document) and UDS for all patients in reducing opioid diversion and abuse. Such measures are new to the primary care setting, and physicians are understandably concerned, in the absence of strong evidence as to their efficacy, that these measures may have a deleterious effect on the quality of physicians’ relationships with patients whose level of function and quality of life may be dependent on opioid analgesia. The approach of “trust but verify” may have had merit in the Cold War, but it could have a chilling effect on the physician–patient covenant.5