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Background There is wide variation in opioid prescribing practices, including opioid quantity and risk mitigation strategies (RMS). Urine drug tests (UDT) are often used as a RMS for patients prescribed opioids. There is a lack of standardized recommendations for these tests. Objective We aim to evaluate differences in prescribing practices, including opioid prescriptions and UDT as an RMS, among patients with multiple opioid prescriptions. Design A retrospective analysis of a national outpatient database of long-term adult opioid prescriptions (≥ 3 prescriptions over a period of at least 120-days) in the United States. Measurements Demographics, abuse history, morphine milligram equivalents (MME), UDT, and frequency were variables of interest. Results 96,994 met the inclusion criteria. Hispanic patients were prescribed less MME/day than non-Hispanics. Examining patients prescribed ≥ 50 MME/day, the highest rates were in American Indian/Alaskan native (8.4%) and White patients (7.5%). At least one UDT was performed in 18,203 (18.8%) patients. When categorized by race, UDTs showed that 25.8% of American Indian/Alaska native, 22.7% of Black patients, 19.2% of multiple races, 18.0% of White patients, 13.5% of Hawaiian/Pacific Islanders, and 12.7% of Asian patients underwent UDTs (p < 0.001). Among the category of ≥ 7 UDTs, Black patients (1.3%) received the most. Upon regression modeling, females (OR 0.94) and uninsured patients (OR 0.66) were less likely to undergo UDT. Among MME categories, patients prescribed 75–99 MME/day had the highest likelihood of UDT (OR 2.4). Those with opioid use disorder (OR 2.64) and tobacco use (OR 1.083) were tested more frequently. When examining race, American Indian/Alaskan natives (OR 1.36), Black patients (OR 1.36), and multiple races (OR 1.245) were more likely to undergo UDT than White patients (reference). Conclusions There is variation in opioid prescribing practices, including opioid quantity and UDT. White patients receive more opioids but less UDT than other populations. Improvements are needed to ensure universal opioid prescribing practices.

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