Focus on Urine Drug Monitoring
Chronic pain is a significant problem in the U.S. today. 35% of patients have chronic pain. Over 50 million Americans are partially or totally disabled by chronic pain. Over the age of 50, one out of two people suffer from chronic pain. Under-treatment of chronic pain runs as high as 50%. With the reversing of the aging of the population this number will be increasing rapidly over the next several decades. The effects of under-treatment of pain can be devastating, including, for example, depression (suicidal ideation), anxiety, loss of sleep, social and sexual dysfunction, loss of work, weakness, fatigue, gastrointestinal distress, hypertension and tachycardia."1 The JCAHO has made pain management one of its number one issues for accreditation for hospitals, and now pain is recognized as the fifth vital sign.2
In their October 23, 2001 Consensus Statement,3 the DEA and 21 healthcare organizations agreed that “effective pain management is an integral and important aspect of the quality of medical care and pain should be treated aggressively." They also noted that opioids are often “the most effective way to treat pain and the only treatment option to provide significant relief." They further stated “that focusing only on the abuse potential of the drugs, however, could erroneously lead to the conclusion that these medications should be avoided when medically indicated, generating a sense of fear rather than respect for the legitimate properties."
In the late 1980s and early 1990s, a major breakthrough in the management of non-malignant pain was the use of opioids. Opioids are the most effective known analgesics. On May 19, 1998, the Federation of State Medical Boards published the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain (revised in 2004).4 These Guidelines recognize that “controlled substances" including opioid analgesics may be essential in the treatment of acute pain due to trauma or surgery and in chronic pain whether due to cancer or non-cancer origins.
Benefits of Drug Testing
The use of a drug-testing program for all patients receiving opioid therapy is essential. Testing patients can reveal other co-morbidities, depression, addiction and poor adherence or compliance. If managed appropriately, patients receive excellent pain relief and, in many cases, are able to achieve improved functionality. Some are able to return to work and even those who do not achieve this goal, may still improve their overall quality of life. A well-designed drug-testing program will allow the physician to determine whether the patient is using illegal drugs or using additional prescription drugs (multiple prescribers). Patients tend to under-report illicit drug use. The abuse of other drugs also increases the risk of adverse drug reactions, overdose, and treatment failure.
So, after all is said and done, what can the physician hope to gain by subjecting the patient to a drug-testing program?
- Drug testing can help provide answers to the following questions:
- Is the patient taking only the specific drugs prescribed?
- Is the patient taking other drugs that in combination could be harmful?
- Is the patient not taking the prescribed drugs?
- The urine drug test serves as documentation that the physician is evaluating the prescribing of drugs to his patient.
- The test program provides information which can help the physician provide better patient care, help identify drug seekers and patients with possible addiction issues.
Establishing A Drug Testing Program
Since there are many different types of programs which can be utilized, it becomes imperative that the physician adopt a program that tests appropriately and specifically for the drugs the physician prescribes. The program should possess the sensitivity to detect those drugs and/or their metabolites at the concentrations that would be consistent with expectations based on the physician’s prescribing dose for the patient. The monitoring program must also address the matrix to test. If the goal is to actually measure the amount of a drug in a patient after he or she achieves a “steady state" concentration, then the tests should be done on plasma or serum. However, if the goal is multi-purpose and includes the need to establish that the patient is not taking a broad base of different drugs and that the patient is taking what is prescribed, then urine may be the best suited specimen to utilize. Urine has been the most extensively studied matrix for testing programs. It will provide not only acute history but also a retrospective look at drug activity for a number of days. Once it has been decided which matrix to test, the next step is to determine which drugs should be included in the testing program.
Urine Drug Testing
Urine drug testing programs generally include various “panels" to choose from. If the focus is on pain management drugs, particularly the opioids, then one needs to choose a panel that will cover those drugs. A sample pain management panel is shown in Table 1 and includes optional add on tests.