__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use • Is the person in pain able to function (e.g., work, do household chores, play) with pain
Urine test results suggesting opioid misuse should be discussed with the patient using a positive, sup- portive approach. The test results and the patient discussion should be documented.
medication in a way that is clearly better than without? If yes, this suggests the pain medication is contributing to wellness. • Does the person smoke? Smoking increases pain and reduces the effectiveness of opioids. Smoking itself is an addictive behavior and, therefore, a clear risk for opioid addiction. If possible, opioids should be avoided persons who smoke. Urine Drug Testing UDTs may be used to monitor adherence to the pre- scribed treatment plan and to detect unsanctioned drug use [113]. They should be used more often in patients receiving addiction therapy, but clinical judgment is the ultimate guide to testing frequency ( Table 10 ) [128]. High-quality evidence supporting the benefits of UDTs in improving patient care are lacking, as much of the existing evidence comes from industry-sponsored studies that can portray a biased perspective, usually by stressing the prevalence of aberrant behaviors in patients who then require more frequent UDT monitoring [129]. Initially, testing involves the use of class-specific immunoassay drug panels [10]. If necessary, this may be followed with gas chromatography/mass spec- trometry 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.
According to the American Society of Interventional Pain Physicians, presumptive urine drug testing should be implemented at initiation of opioid therapy, along with subsequent use as adherence monitoring, using in-office point of service testing,
followed by confirmation with chromatography/mass spectrometry for accuracy in select cases, to identify patients who are noncompliant or abusing prescription drugs or illicit drugs. Urine drug testing may decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (https://painphysicianjournal.com/current/pdf?article= NDIwMg%3D%3D&journal=103. Last accessed August 15, 2023.) Level of Evidence : III (Evidence obtained from at least one relevant, high-quality nonrandomized trial or observational study with multiple moderate- or low- quality observational studies) Ethical Concerns with UDTs It is important to appreciate the limitations of UDTs. Healthcare 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 informa- tion they obtain, the accuracy of urine screens, and whether some companies and clinicians are finan- cially exploiting the UDT boom [129]. 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
MONITORING FREQUENCY ACCORDING TO PATIENT RISK
Monitoring Tool
Patient Risk Level
Low
Medium
High
Urine drug test
Every 1 to 2 years
Every 6 to 12 months
Every 3 to 6 months
State prescription drug monitoring program
Twice per year
3 times per year
4 times per year
Source: [128]
Table 10
33
MDMS1526
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