Other ways to objectively monitor opioid use are checking prescription drug monitoring programs, completing urine drug tests/oral fluid tests, or random pill counts. Relatively infrequent urine monitoring may be appropriate for low-risk patients on a stable dose of opioids (i.e., 1-2 times a year). More frequent or intense monitoring is appropriate for patients during the initiation of therapy or if the dose, formulation, or opioid medication is changed. Patients who may need more frequent or intense monitoring (i.e., 4-6 times a year) include: 104 • Those with a prior history of an addictive disorder, past abuse, or other aberrant use • Those in an occupation demanding mental acuity • Older adults • Patients with an unstable or dysfunctional social environment • Those with comorbid psychiatric or medical conditions It is important to recognize that urine drug testing is expensive and not all insurance companies will pay for frequent testing. Discuss the cost of testing with patients. Also, only order the test that is necessary. It is not necessary to order quantitative (definitive test) testing on all patients as this test can be very expensive. For low-risk patients urine drug screening (presumptive test), even done as a point of care test, may be sufficient. However, if the urine drug screen will not detect the drug of interest, then a quantitative test will be needed. Trust is a necessary part of any patient/ clinician relationship, but studies suggest that in the context of controlled substances, it is unwise to rely on a patient’s word that medications are being consumed as prescribed. Although the use of more objective ways to monitor adherence to medication regimens is an imperfect science, such methods remain an essential component of periodic review. Multiple objective methods to assess adherence exist, but there is no single “best” approach and all such methods have both advantages and potential drawbacks. In the context of family practice settings (and even pain specialist settings) unobserved urine collection is usually an acceptable procedure for drug testing. Prescribers, however, should be aware of the many ways in which urine specimens can be adulterated. Specimens should be shaken to determine if soap products have been added, for example. The urine color should be noted on any documentation that accompanies the specimen for evaluation, since unusually colored urine could indicate adulteration. Urine temperature and pH should be measured immediately after collection when possible. 131
Prescribers should be familiar with the metabolites associated with each opioid that may be detected in urine, since the appearance of a metabolite can be misleading. A patient prescribed codeine, for example, may test positive for morphine because morphine is a metabolite of codeine. Similar misunderstandings may occur for patients prescribed hydrocodone who appear positive for hydromorphone or oxycodone and oxymorphone. Opioid rotation and equianalgesic dosing “Opioid rotation” means switching from one opioid to another in order to better balance analgesia and side effects. Rotation may be needed because of a lack of efficacy (often related to tolerance), bothersome or unacceptable side effects, increased dosing that exceeds the recommended limits of the current opioid (e.g., dose limitations of co- compounded acetaminophen), or inability to absorb the medication in its present form (i.e., if there is a change in the patient’s ability to swallow, switch to a formulation that can be absorbed by a different route such as transdermal.) Because of the large number of variables involved in how any given opioid will affect any given patient, opioid rotation must be approached cautiously, particularly when converting from an immediate-release formulation to an ER/LA product. As noted previously, equianalgesic charts must be used carefully, and titration must be done carefully and with appropriate monitoring. In some cases, because of the risk of potential harm during the time of rotating from one chronic opioid regimen to another, it may be wise to initially use lower doses of an ER/LA opioid than might be suggested by equianalgesic charts, while temporarily liberalizing, as needed, the use of a short-acting opioid. 138 This would then be followed by gradual titration of the LA opioid to the point where the as-needed short- acting opioid is incrementally reduced, until no longer necessary. Equianalgesic dosing charts help clinicians determine the appropriate starting dose of an opioid when changing routes of administration or when changing from one opioid drug to another. Such charts must be used carefully, however. A high degree of variation has been found across the various charts and online calculator tools, and may account for some overdoses and fatalities. 132 The optimal dose for a specific patient must be determined by careful titration and appropriate monitoring, and clinicians must be mindful that patients may exhibit incomplete cross-tolerance to different types of opioids because of differences in the receptors or receptor sub-types to which different opioids bind. 138 In addition, the patient’s existing level of opioid tolerance as well as concurrent medications that depress the central
nervous system must be taken into account. Printed equianalgesic charts are common, and online calculators are also freely available (a common one can be accessed at clincalc.com/Opioids). Always work with a clinical pharmacist if you do not have a lot of experience with opioid rotation as this can be a risk factor for unintentional opioid overdose. Recognizing patients with opioid use disorder Whenever a clinician considers treating pain with a controlled substance, such as an opioid, risk of misuse or diversion is always a possibility, no matter how remote, and must be assessed. Some patient characteristics are predictive of a potential for drug abuse, misuse, or other aberrant behaviors. The factor that appears to be most strongly predictive in this regard is a personal or family history of alcohol or drug abuse. 28 Some studies have also shown that younger age and the presence of psychiatric conditions are also associated with aberrant drug- related behaviors. 28 In evaluating patients with chronic pain for risk of addiction or signs that they may be abusing a controlled substance, it may be helpful to consider the sets of characteristics listed in Table 5. Signs of physical dependence include the appearance of an abstinence syndrome with abrupt cessation or diminution of chronic drug administration and is not the same as OUD, a condition where patients lose control of their opioid use or compulsively use opioids. The nature and time of onset of this syndrome vary with drug actions and half-life. Slow tapering of the drug (e.g., 10-15% reduction in dosage per day or every other day) usually avoids the appearance of an abstinence syndrome. Managing Non-Adherent Patients Patients who exhibit aberrant drug-related behaviors or non-adherence to an opioid prescription should be monitored more closely than compliant patients. Concern that a patient is non- adherent should prompt a thorough evaluation. The way clinicians interact with patients can affect the relationship (for better or worse) and influence treatment outcomes. A clinician’s negative reactions to non-adherence might include anger at the patient, disappointment and sadness at the apparent betrayal of trust, or fear that the patient’s behavior could expose the provider to legal jeopardy. 104 The use of patient–provider agreements and/ or informed consent documents can help clinicians navigate the uncertainties that can arise in cases of real or apparent non-adherence, and may help make the process less confrontational. Consultation with an addiction medicine specialist or psychiatrist may be necessary if addiction is suspected or if a patient’s behavior becomes so problematic that it jeopardizes the clinician/patient relationship.
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