Is it time to drug test your chronic pain patient?

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Applied Evidence

Is it time to drug test your chronic pain patient?

J Fam Pract. 2010 November;59(11):628-633

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References

1. Health Care Issues. Joint Commission on Accreditation of Health Care Organizations. Available at: http://www.jointcommission.org/. Accessed March 5, 2010.

2. Standards, Laws, and Regulations Addressing Pain Medications and Medical Practice: Report 6 of the Council on Science and Public Health. American Medical Association. June 2007. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-science/council-science-public-health.shtml. Accessed July 16, 2009.

3. US Department of Justice Drug Enforcement Administration Office of Diversion Control. Available at: http://www.deadiversion.usdoj.gov/. Accessed March 5, 2010.

4. Federation of State Medical Boards. Model Policy for the Use of Controlled Substances for the Treatment of Pain. May 2004. Available at: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Accessed March 5, 2010.

5. Centers for Disease Control and Prevention. Prescription Drug Overdose: State Health Agencies Respond. Available at: http://www.cdc.gov/HomeandRecreationalSafety/pubs/RXReport_web-a.pdf. Accessed May 15, 2010.

6. Drug Enforcement Agency Office of Diversion Control NFLIS Special Report: Controlled Substance Prescription Drugs 2001-2005. November 2006. Available at: http://www.deadiversion.usdoj.gov/nflis/2006rx_drugs_report.pdf. Accessed May 15, 2010.

7. Department of Health and Human Services Office of Substance Abuse and Mental Health Services Administration. Results from the 2007 National Survey on Drug Use and Health: national findings. Available at: http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf. Accessed May 7, 2010.

8. Reisfield G, Salazar E, Bertholf R. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37:301-314.

9. Clinical Pharmacology [online]. Tampa, FL: Gold Standard Inc; 2010. Accessed March 5, 2010.

10. Drug abuse urine tests: false-positive results. Pharmacist’s Letter/Prescriber’s Letter. 2005;21:210314.-

11. Reisfield GM, Webb FJ, Bertholf RL, et al. Family physicians’ proficiency in urine drug test interpretation. J Opioid Manag. 2007;3:333-337.

12. Adams N, Plane M, Fleming M, et al. Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796.

13. Gourlay D, Caplan Y, Heit H. Urine drug testing in clinical practice: dispelling the myths and designing strategies. San Francisco, CA: California Academy of Family Physicians; 2006.

14. Cole BE. Recognizing and preventing medication diversion. Fam Pract Manag. 2001;8:37-41.

15. Jackman R, Purvis J, Mallett B. Chronic nonmalignant pain in primary care. Am Fam Physician. 2008;78:1155-1162.

16. Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.

17. Chou R, Fanciullo G, Fine P, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline. J Pain. 2009;10:131-146.

18. Moeller K, Lee K, Kissack J. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83:66-76.

19. Amabile C, Bowman B. Overview of oral modified-release opioid products for the management of chronic pain. Ann Pharmaco-therapy. 2006;40:1327-1335.

20. Zhou S. Polymorphism of human cytochrome P450 2D6 and its clinical significance. Clin Pharmacokinet. 2009;48:689-723.

21. Drug Facts and Comparisons [online]. 2010. Available at: http://www.factsandcomparisons.com/. Accessed March 5, 2010.

TABLE 1
Aberrant drug-related behavior: Red flags^13-15

Use of opioids for non-analgesic indications
Lack of control (related to drug use or to patient behavior)
Compulsive use of medications
Continued use of drugs despite harm/lack of benefit
Cravings
Escalation of drug use
Selling/altering prescriptions
Theft or diversion
Request for early refills
Claims of “lost” prescriptions
Reluctance to try nonpharmacologic options
Use of multiple prescribers or pharmacies
Odd stories regarding need for medication
Reporting vague medical history or textbook symptoms
Unwillingness to name regular physician
No interest in a physical exam, diagnostic testing, or providing past records
Request for specific drug(s)
Extensive (or very limited) understanding of medications
Calling or arriving after hours or when regular doctor is unavailable
Insistence on being seen urgently (eg, because of being late for another appointment)

When to test, what to test for
No guidelines specify when to test, but testing upon initiation of chronic opioid treatment, followed by random testing, is the most widely used strategy. Unobserved specimen collection is generally acceptable,¹³ provided the specimens are requested at random rather than routinely at every visit.

FAST TRACK

Ask laboratory personnel which drugs are included in their facility’s urine test panel and what the lower limits are; both vary from 1 facility to another.

Initial testing is done using an immuno-assay drug panel.^13,18 TABLE 2 lists the drugs most commonly included in a standard urine test. However, the drug panel can vary from 1 laboratory to another, as can the lower limits of drug detection. No-threshold testing is mentioned in pain management literature, but is not often available in clinical practice.

Before initiating UDT, it is important to know which drugs the laboratory you use routinely tests for and what its lower limits are. The simplest way to find out is to ask lab personnel.

FAST TRACK

Avoid making patients feel stigmatized by explaining that urine drug testing is a standard monitoring protocol in your office.

CASE 1 At her first visit, Marilyn H’s new physician focuses on controlling her blood sugar and blood pressure, ordering follow-up testing of the lung nodule, and refilling her hydrocodone and alprazolam prescriptions. The physician requests the patient’s medical records and orders a urine drug screen per clinic protocol, testing for benzodiazepines as well as for opioids. He gives his patient prescriptions for a 1-month supply of both drugs while the UDT results are pending.

The lab report comes in the following day, and indicates that Marilyn tested positive for cocaine but negative for other substances, including narcotics and benzodiazepines. The clinic immediately notifies the pharmacy to confiscate the patient’s new prescriptions when she presents them and calls Marilyn, advising her that she will not be given any further prescriptions for controlled substances.

The physician refers the patient to a pain clinic, gives her the number of a substance abuse treatment center, and encourages her to follow up at the clinic for other medical issues. Marilyn fails to keep her appointment at the pain clinic and does not respond to a subsequent call.

TABLE 2
A standard urine drug test panel^13,18

Amphetamines
Cocaine
Marijuana (THC)
Opiates (morphine and codeine)
Phencyclidine
THC, tetrahydrocannabinol.

Talking to patients about drug testing
Physicians are often concerned about patients’ feelings about drug testing—worrying that patients may not feel trusted or respected by a doctor who asks them to submit to UDT. Others may fear that the mere mention of urine testing will encourage patients to misuse prescription opioids, that patients will view UDT as a punitive measure, or that those being tested will believe that the physician is more concerned with self-protection than with providing optimal care to the patient.

Making UDT routine. One way to circumvent such possibilities is to implement a systematic approach to drug testing. We recommend that physicians discuss the role of UDT in the initial education session with patients being started on a course of opiates. Describing UDT as simply another routine monitoring parameter—akin to the measure of microalbuminuria for patients with diabetes—can decrease or eliminate the stigma associated with drug testing.

CASE 2 A new policy encouraging UDT for all patients on chronic controlled substances has just been implemented at the clinic where Don F is being treated. His physician tells him about the policy, and a urine test is ordered at his next visit. The test comes back negative for all substances, including opioids.

When presented with the results over the phone, Don insists that he regularly takes his prescription medication, and makes a same-day appointment to discuss the results with his physician.

Interpreting test results— what UDT can (and can’t) reveal

To avoid eroding trust by falsely accusing a patient of diversion or use of an illicit substance, it’s important to familiarize yourself with testing limitations. Factors that can affect the results, and may interfere with the ability of UDT to provide a definitive picture, include: