Tumblin’ Dice–Why Does Random Matter?
Before making clinical decisions, and regardless of whether a patient is a raucous rock and roller or a tranquil librarian, data must be gathered in an objective manner. Assessing outcomes of interventions is essential data. This is as true when managing chronic pain as it is with any other condition. The intended therapeutic outcomes of opioid drug interventions are pain relief and improved function. Aside from physiologic derangements—e.g. respiratory depression, sedation, pruritis, and constipation—drug diversion, abuse, and addiction are potential adverse outcomes with any patient. Physicians need to screen for these adverse outcomes objectively and fairly.
The Federation of State Medical Boards expects physicians to incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances.1 With early detection of signs of drug problems, physicians are afforded the opportunity to take measures to ameliorate the effects of diversion, abuse, and addiction. Examples of such safeguards are:
- frequent follow-ups and re-evaluations
- review of old medical records
- drug utilization reports/pharmacy records
- information from collateral sources (e.g. family members)
- communication with other physicians
- inventory of pills—“pill counts”
- urine drug testing
Compared with the others listed, urine drug testing has unique value. The fact that a patient is willing to submit to a drug test decreases the risk of an undiagnosed drug misuse problem.2 Urine drug testing, being a laboratory procedure, is presumed to be objective and reliable. The patient actively participates by providing the specimen. Urine drug testing is by no means clandestine or covert; the patient is quite aware it is taking place. Urine drug testing need not imply a judgment of the patient but, instead, engage the patient in a cooperative effort to care for pain and well-being.
Historically, urine drug testing has been seen by the patient and physicians as adversarial and punitive, rather than therapeutic. The connotation may be that taking pain medications is somehow wrong and that the patient is not to be trusted to self-report in a truthful manner. Understandably, if only the patients who displayed dysfunctional behavior were drug tested, those selected for drug testing would feel accused of wrongdoing. It is thus vital that the stigma associated with urine drug testing be diminished and the bond of trust strengthened between the patient and physician. Urine drug testing that is random and fairly applied avoids the stigma and builds therapeutic trust.
Random urine drug testing can strengthen the physician-patient relationship and allow communication of appropriate concerns, expectations, and broad therapeutic goals. The most important step in removing the stigma associated with drug testing is to view it as a therapeutic measure as opposed to a regulatory measure. The goal must be to promote safety, not to punish. When drug testing in the clinical setting is conducted properly, communication with the patient can be strengthened and the bond of trust can be clarified. To achieve this goal, indications should be universally applied to all patients, not just patients with worrisome behaviors (i.e. “red flags”).3,4 Patients should have a clear understanding up front that drug testing is part of the normal routine.
Indications to perform urine drug tests should be individualized to each patient and tests performed:
- when initiating therapy
- when function declines
- when changing therapies
- when patients are resistant to full evaluations
- when patients are unwilling to try other therapies or request specific drugs
- when aberrant behaviors are detected
Of the listed indications, it is the random test that may be most effective in reducing the stigma for the following three reasons:
- A truly random test is fair. No one can legitimately claim to be targeted.
- Relying only on dysfunctional behaviors to trigger a urine drug test will miss more than 50% of drug abusers.5
- Random urine drug testing assures regular communication about critical potential adverse treatment effects and broadens psychosocial adjustment concerns.
The question then remains, how does one easily and fairly decide when a random test should take place? And how can it be applied in a universal manner?
Several methods have been suggested:
- pulling names out of a hat or any variety of lottery systems,
- testing patients at set intervals (e.g. every 10th patient),
- using a “magic eight ball” or roulette wheel,
- devising a computer program to randomize the patients,
- rolling dice.
Most patients are familiar with rolling dice. It is undeniably fair. The act of placing the dice in the patient’s hand is a tactile and visual reminder that there are important boundaries and responsibilities when controlled substances are utilized. By allowing the patient to roll, the patient self-determines whether or not the drug screen will be performed. If the patient objects to rolling dice because of moral or religious reasons, or when a gambling addiction exists, the practitioner can roll the dice on behalf of the patient.
A sample from a letter explaining the program, which can be posted or distributed, is reproduced below.
Regulatory agencies expect physicians to employ safeguards in their practice to minimize abuse and diversion, and documenting drug tests helps show auditors this expectation is being met. The process of drug testing should be therapeutic—not punitive. Results can document compliance and advocate for the patient in family and social issues. When considering methods that assure a fair, universally applied, and random technique for triggering urine drug tests, rolling dice is a simple way to effectively monitor potential adverse treatment effects and to build a clear and productive therapeutic relationship with your patients.
In case you are wondering, our clinic has not become a part -time casino, but you will have the opportunity to “roll the dice” when you visit. As you are probably aware, some of the medications we prescribe are “controlled substances” (e.g. oxycodone, morphine, hydrocodone, etc.). While regulatory agencies, such as the DEA, Board of Medical Licensure, and police, require us to monitor our patients who take these medications, most importantly we do it to promote your safety. Therefore, to help provide you with safe and responsible healthcare we will randomly require you to participate in urine drug testing. In order to be fair and not make you feel singled-out, we have instituted the following policy. At each appointment, you will roll two dice. If you roll a “2” or a “12” (1 in 18 chance) you must submit to a urine drug screen.