Developing a Safe Opioid Treatment Plant for Managing Chronic Pain ________________________________
rigid adherence without closer assessment may lead to further withholding of pain treatment from patients already distressed by pain. INVOLVEMENT OF FAMILY MEMBERS Family members of the patient can provide valuable informa- tion that better informs decision making regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regarding positive or negative changes in patient function, attitude, and level of comfort. The follow- ing questions can be asked of family members or a spouse to help clarify whether the patient’s response to opioid therapy is favorable or unfavorable [8]: • Is the person’s day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treat- ment options. • Does the person take pain medication only on occa- sion, perhaps three or four times per week? If yes, the likelihood of addiction is low. • Have there been any other substance (alcohol, tobacco, or drug) abuse problems in the person’s life? An affirma- tive response should be taken into consideration when prescribing. • Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, this sug- gests the pain medication is failing to promote rehabili- tation. Daily activity is essential, and the patient may be considered for enrollment in a graduated exercise program • Is the person in pain able to function (e.g., work, do household chores, play) with pain medication in a way that is clearly better than without? If yes, this suggests the pain medication is contributing to wellness. • Does this patient smoke? Smoking increases pain and reduces the effectiveness of opioids. URINE DRUG TESTING UDTs may be used to monitor adherence to the prescribed treatment plan and to detect unsanctioned drug use [4]. They should be used more often in patients receiving addiction therapy, but clinical judgment is the ultimate guide to testing frequency ( Table 1 ) [16]. Although there has been a general consensus in pain management guidelines for the use of UDTs prior to initiating and during opioid therapy, evidence supporting the benefits of UDTs in improving patient care is weak [17]. Clinicians should consider the benefits and risks of toxicology testing [1]. Initially, testing involves the use of class-specific immunoas- say drug panels [4]. If necessary, this may be followed with gas chromatography/mass spectrometry for specific drug or metabolite detection. It is important that testing identifies the specific drug rather than the drug class, and the prescribed
opioid should be included in the screen. Any abnormalities should be confirmed with a laboratory toxicologist or clinical pathologist. Immunoassay may be used point-of-care for “on- the-spot” therapy changes, but the high error rate prevents its use in major clinical decisions unless liquid chromatography is coupled with mass spectrometry confirmation. Urine test results suggesting opioid misuse should be discussed with the patient using a positive, supportive approach. The test results and the patient discussion should be documented. Ethical Concerns with UDTs It is important to appreciate the limitations of UDTs. Health- care providers are increasingly relying on UDTs as a means to reduce abuse and diversion of prescribed opioids. This has led to a proliferation in diagnostic laboratories that offer urine testing. With this increase have come questions of whether these business interests benefit or hinder patient care, what prescribers should do with the information they obtain, the accuracy of urine screens, and whether some companies and clinicians are financially exploiting the UDT boom [18]. Despite wide endorsement and making intuitive sense, there is little empirical confirmation that UDTs reduce prescription opioid abuse [1; 6]. A random sample of UDT results from 800 patients with pain treated at a Veterans Affairs facility found that 25.2% were negative for the prescribed opioid and 19.5% were positive for an illicit drug/unreported opioid [19]. However, a negative UDT result for the prescribed opioid does not necessarily indi- cate diversion; it may indicate the patient halted its use due to side effects, lack of efficacy, or pain remission. The increasingly stringent climate surrounding clinical decision-making regard- ing aberrant UDTs is concerning. In many cases, a negative result for the prescribed opioid or a positive UDT serves as the pretense to terminate a patient rather than an impetus to guide him or her into addiction treatment or an alternative pain management program [18]. The FSMB recommends not using toxicology testing in a punitive manner and instead using it as a chance to inform and improve patient care [4]. In principle, and ideally in practice, UDTs are a worthwhile element of effective pain management and pharmacovigilance when used to enhance the diagnostic and therapeutic objec- tives of pain therapy. However, immunoassay screens have high false-positive and false-negative rates and only provide qualita- tive information about a select number of drug classes [17]. As a side note, cannabis use by chronic pain patients receiving opioid therapy has traditionally been viewed as a treatment agreement violation that is grounds for termination of opioid therapy. However, some now argue against cannabis use as a rationale for termination or substantial treatment and monitor- ing changes, especially considering the increasing legalization of medical use at the state level [20]. In addition, there is a substantive and growing body of research confirming cannabis efficacy (and opioid-sparing effects) in chronic pain conditions, including neuropathic pain, cancer pain, fibromyalgia, and headache pain [21; 22; 23; 24; 25].
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MDNJ1525
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