What’s Best When Choosing a Prescription Drug Monitoring Program?
Every time I visit my family physician, he asks the same question; “Still taking your statin?” Of course, the answer is “yes”. But if the answer were “no”, he would have no concerns other than for my heart health. Fortunately as of today, statins have not given way to any recreational misadventures that raise concerns about diversion or abuse. Unfortunately, from my time spent working in post-mortem toxicology, the same cannot be said of Schedule II drugs such as the opiates. With 100 million Americans experiencing chronic pain and the subsequent increase in prescriptions to improve their quality of life, the abuse of prescription medications has become a national issue. Prescription drug abuse now outpaces cocaine abuse. The weight of the question of prescription compliance places the physician at the frontline of finding a solution to the issue.
Being thrust into this position puts the clinician in the role of “detective” or “enforcer”, either of which is a distraction from providing quality care to the patient. The need to provide pain relief now carries the added burden of having the “right” program in place to monitor prescription compliance. One of the most used and relied upon tools is the urine drug test.
Isn’t it true that if your urine drug test is negative for opiates you must not be taking your prescription? Seems like a natural conclusion, with the next step being the dismissal of the patient from the practice. But you have known this patient for years, she couldn’t possibly be diverting; she teaches in the local school. Should you try an alternate matrix such as blood? Surely blood is the most accurate test, but is it? Does the laboratory provide sufficiently sensitive tests? Wouldn’t it be more convenient to provide point of care testing in my office? What about cross-reactivity? Could it be the lower dose I have prescribed? What about genetic differences in metabolism of opiates? You think you have the best tool in the shed, but as they say, “is it the sharpest”?
While a urine drug test is only a part of the clinical decision process, its use has become standard practice. But the intricacies of urine drug testing aren’t always so obvious.
In December 2011, Quest Diagnostics participated in a project utilizing social media to help clinicians develop a better understanding of the laboratory’s role in developing an effective pain management prescription drug montioring program in their practices. Quest Diagnostics participated as a “Guest Expert” to help provide additional insight to typical questions that healthcare providers have concerning urine drug monitoring. While we hopefully informed on issues such as why urine is the preferred specimen, the utilization of new pharmacogenetic testing and the interpretation of discrepant test results, we also gained insight into the state of the physician awareness of pain management testing. As part of the posting, five survey questions were posed to those who viewed the post:
- Q1: What type of prescription drug/pain management monitoring do you perform on your patients?
- Q2: Which sample type do you feel is most accurate for monitoring chronic pain patients?
- Q3: What action(s) do you take when a patient's test result is negative for prescribed medication?
- Q4: When was the last time you participated in a Continuing Education event on pain management testing?
- Q5: Do you feel you are able to successfully manage the pain of your chronic pain patients?
Three major groups represented the majority of the respondents: Pain Management (PM) specialists, Internal Medicine (IM) and Family Practice (FP) physicians.
While the majority of respondents used some form of pain management monitoring (78%), an average 22% of responding physicians (excluding PM) did not currently perform any PDM. It is both concerning and eye-opening that with all the media exposure of the social issues surrounding the misuse of opiates that one in five physicians do not test their patients for compliance.
Almost two-thirds of respondents (64%), across specialties, report that urine provides the most accurate measure of chronic pain in patients; blood garnered more than a quarter of the total confidence share. The fact that 30% of responding clinicians (range: 27% - 33%) believe blood is the most accurate specimen raises the question of the understanding the value of each type of specimen for prescription drug monitoring. Urine provides the longest window of detection, the presence of parent drug and/or metabolites and higher concentrations of both parent/metabolite. While blood may better reflect efficacy of treatment, the lack of sufficient sensitivity for most assays limits its usefulness in the pain management arena. A final interesting note about sample selection is that approximately 7% felt hair was the most accurate. While hair can give a 90 day window of detection, it cannot discriminate when within that window the dose was consumed: currently, hair is not a valid sample type for PDM.
In response to Q3, the majority of respondents (64%) would recommend a combination of the following: counseling, re-testing and/or patient dismissal. 10% would recommend dismissal of the patient as the only course of action. An associated anecdotal finding was particularly interesting. Respondents felt a “negative” result was equitable to a “0” or no drug present. This is not necessarily true as the majority of reported results are judged against a cutoff value. A concentration of drug just below the reported cutoff value does not mean it is not present! Once again a lack of understanding of the practice of laboratory testing indicates the need for more education of providers.
Another question found participation in continuing education events focusing on pain management is low; over a third of respondents (36%) report no prior engagement in any such events. But even those who have participated in the past 12 months accounts for only 17% on average for all groups. This emphasizes the need for specific continuing education on the subject of pain management in order to enhance the clinician’s practical knowledge on this subject. Given the responses for the first three questions, one could argue that this continuing education needs to be directed not only broadly in the area of PDM protocol development, but specifically in the area of laboratory testing and urine drug monitoring.
The final question summarizes the overall perspective of how our survey group felt about their comfort with PDM. While 93% of PM specialist felt they were adequately managing their patient’s chronic pain, only 59% on average of the remaining respondents felt they were being successful. Given the lack of participation in continuing education plus limited professional training specifically for pain management during their medical education, it could be said that education on PDM is the key to reversing this trend. This is especially true for those physicians whose specialty is not Pain Management.
From this analysis, the overall trends seem to suggest that the best course of action at this point is physician education. More specific information concerning the role and value of laboratory testing for chronic paint patients needs to be disseminated to the practicing clinicians who are caring for these patients.