Toxicology

To simplify Toxicology as it pertains to Urine Drug Testing, it is the primary method of medication monitoring available for physicians to assist in the managing the complex treatment of chronic or acute pain. The major drugs that are available for pain management have limitations and have a high potential for abuse or misuse. One of the many concerns in pain management is the identification of patients that have aberrant drug-related behavior or a potential for addiction or abuse. The abuse and diversion of controlled prescription medications has been labeled by some as a public health crisis. Urine drug testing is strongly recommended under Federal, State, and Clinical guidelines, to be used when treating intractable chronic pain with opioids. It is a highly useful tool to verify patient compliance with your treatment plan, and to potentially expose unreported drug use or diversion of the prescribed medication. A UDT Program helps doctors by providing an objective way to document patient adherence to the treatment plan and also to confirm patient abstinence from non-prescribed drugs of abuse.

Foundational Education

Throughout the past many decades, attention has been drawn to the fact that the incidences of untreated and unrecognized pain have increased. Beginning in the 1990’s, doctors were starting to recognize this issue and through educational efforts, began to assess and treat pain more aggressively. These efforts reached full stride around 2000 when the U.S. Congress proclaimed the years 2000-2010 the Decade of Pain Control and Research.

The prescribing of opioids increased substantially when both the American Pain Society and the American Academy of Pain Medicine wrote formal positions endorsing the prescription and use of chronic opioid therapy (COT) for pain. The increased availability of opioids has lead to some unanticipated problems, including and high incidence of nontherapeutic opioid use. Currently, deaths from misuse of opioids exceed deaths from heroin use, proving that there is a huge issue with nontherapeutic use of opioids in the United States.

It is shown that two-thirds of abused opioids originate from a valid prescription and one-fifth are obtained from more than one physician. It is estimated that the economic burden for prescription opioid abuse in 2005 was $9.5 billion. The prevalence of addiction in the general population is estimated to be between 3-16%. What is worrisome is that many patients with chronic pain who believe they need COT are psychologically distressed. Patients with mental health and/or substance abuse disorders are at greatest risk for using controlled substances nontherapeutically and studies have proven that to be true by showing that COT use increases more rapidly with patients who have mental health issues.

One of the main problems lies with how pain is reported. Clinicians must rely heavily on subjective reports from their patients to make important treatment decisions. Patients who suffer with addiction many times will not provide truthful self-reports if the report could result in their not receiving their drug of choice. Often times self-reported drug use in the chronic pain population is unreliable. This issue leads the physician to combine subjective input and objective observations to assess their patients. Objective observations include pill counts, prescription monitoring programs, and monitoring the patient for aberrant behavior.

Aberrant behavior can vary greatly depending on the patient, but often times may include one of many of the following: early refill requests, reports of lost or stolen medications, and treatment noncompliance. Monitoring aberrant behavior is quite inadequate and frequently results in underestimated aberrant drug-taking behavior. The physician must incorporate other tools such as urine toxicology testing in order to successfully flag and monitor nontherapeutic use of opioids.

Scientific Basis of Urinary Drug Testing (UDT)

Toxicology as it applies to urine testing in a Pain Management clinical setting (UDT) as a means to assure compliance and monitoring of proper medication use is becoming common place in the clinical practice of pain management.

Urine is the standard body fluid tested for drug screening because it is non-invasive, readily available, and is easily handled by office personnel and laboratories. Urine drug testing is preferred over serum testing because the period of detection of a particular drug in the urine is increased, whereas their corresponding metabolites in the serum may only be setectable for a short period of time.

UDT is becoming the cheapest insurance for liability protection in the clinical practice. It decreases the risk physicians have in selecting a treatment modality when treating patients for chronic pain. The Federation of State Medical Boards (FSMB) and the Drug Enforcement Agency (DEA) both have standards set forth in dealing with the implementation of monitoring drug compliance and both require regular use of UDT.

UDT is a very useful tool in pain management. It provides valuable objective information to aid in therapeutic and diagnostic decision making. This tool also provides confirmation of the agreed upon treatment plan, can diagnose relapse or drug misuse, and can also be used to advocate for the patient with third-party interests.

Why Should a Physician Order UDT?

It is a well known fact that self-reporting of nontherapeutic drug use among patients with chronic pain treated with opioids is often unreliable. Patients may fail to disclose use of illicit drugs, medications prescribed by other healthcare providers, use of nonprescription medications, or even use of prescribed medication. Most physicians would agree that information pertaining to a patient’s inappropriate use of nonprescribed medications or illicit drugs is essential for proper patient management. The use of external information such as interviews with spouses, review of medical records, input from prescription monitoring programs, and urine toxicology testing may improve patient outcome.

According to the Drug Enforcement Agency:

  • Approximately 7 million Americans are abusing prescription drugs. This represents an 80% increase since 2000.
  • Drug users report to prefer pain relievers over cocaine or marijuana
  • Opioids cause more drug overdose deaths than cocaine and heroin combined.
  • 1 in 10 high school students admits to abusing prescription painkillers.
  • 25% of drug-related emergency clinic visits are associated with prescription drug abuse.
  • The misuse of pain medications represents three-fourths of the overall problem of prescription drug abuse.
  • “doctor-shopping”, traditional drug dealing, pharmacy and home theft, requiring drugs from the internet, and acquiring drugs from relatives and friends are some of the most common methods of acquiring prescription drugs for abuse.
  • The DEA works closely with the medical community to help recognize drug abuse. Doctor involvement in illegal drug activity is rare, but the DEA pursues criminal activity against such practitioners.

Prescribing physicians and in particular, pain management practitioners, have one of the most important and most scrutinized roles in this effort.

Adhering to a structured Toxicology Program will support the assessment and diagnosis, document patient compliance to a treatment plan, confirm abstinence from non-prescribed drugs, and discourage “doctor shopping”.

Who Should Physicians Test?

  • New patients already taking a controlled substance
  • Any patient for whom a physician is considering prescribing a controlled substance
  • Patients who are resistant to a full evaluation
  • Patients who request a specific drug(s)
  • Patients who display aberrant behavior
  • Patients in recovery from substance abuse

Clinical Outcomes from UDT

UDT should not be mainly used to protect the physicians license or the pain clinic, but to enhance patient care. The presence of an illicit substance in the urine indicates that the patient has a problem and needs help and guidance from the physician. It is a disservice to discharge a patient on the basis of a positive UDT, instead the patient should be offered help in the form of a treatment with an addiction medicine specialist, psychiatrist, or clinical psychologist specializing in addiction. In this case, the patient’s chronic pain should be managed by other means besides opiates.

Clinically, the benefits of UDT are multiple. These include reducing the risk for toxicity in patients vulnerable to adverse drug effects, avoidance of medico-legal problems, detecting patient non-compliance, reducing the risk of therapeutic failure, and avoiding or detecting drug-drug interaction. Additionally, UDT enhances the physician’s ability to use drugs effectively and minimizes treatment costs.

UDT is an important tool with many benefits such as: reducing the risk of toxicity, detecting patient non-compliance, reducing the risk of treatment failure, decreasing the incident of drug misuse, uncovering prescription abuse or misuse, and avoidance of medico-legal problems. The UDT enhances the physician’s ability to use drugs effectively and minimize treatment costs.

It has to be emphasized that the result of urine toxicology for the purpose of detecting patients who may be diverting, supplementing or abusing the prescribed drugs and other illicit substances are protected by the physician-patient confidentiality rule and the result of the test cannot be disseminated to other interested parties without the expressed consent of the patient.

Unexpected Urine Toxicology Results

The use of UDT should be consensual; it is designed to improve patient care and to assist the healthcare professional to advocate on the patients behalf. UDT results may come back negative for a prescribing drug or positive for an unprescribed drug. If this occurs, the first step should be to contact the lab to ensure no clerical errors have been made. If the unexpected results are confirmed, there must be a process in place that should include discussing the results with the patient.

Toxicology Summary

The Rising Epidemic. According to a recent CDC study, pain reliever abuse has increased 111% in the last 5 years. Non-medical use of narcotics has skyrocketed, and physicians can be placed in the awkward situation of having to decide whether or not a patient’s pain medication use is legitimate.

Protecting the Patient.Imagine yourself waking up in pain every single day, and you are under the care of a physician prescribing you pain medication. In order to ensure compliance and place confidence in the patient-physician relationship, your doctor may necessitate a urine drug test. This will guarantee that you are taking the drugs prescribed and only those medications. If you were to stray from the prescribed from those medications, you could be placing your health at risk. Narcotic medications can have significant cross-reactions with other medications. A urine drug test ensures patient compliance with the prescribed regimen and may prevent an unnecessary adverse event.

Protecting the Doctor. Even under the most humane and disease related indications, physicians face significant risks by prescribing controlled medications. Patients may divert their prescription, take too much, combine with illicit substances, etc. These risks are mitigated by physicians subjecting patients to urine drug screening, pill counts, pain agreements, and if the state has it review of the patient on the pharmacy board’s website. The vast majority of patients are compliant, however a small few have necessitated the testing from resultant adverse events.

The Bottom Line. Pain management safeguards are necessary in this day and age to protect both the patient and provider for different reasons. The common denominator is pain relief and improved quality of life for the patient, while at the same time providing for the highest level of patient safety and minimizing the chance of prescription diversion.