Who and When to Test: Determining When
When and how frequently should patients taking prescribed opioid medication to treat chronic pain undergo urine drug testing (UDT)? Some primary care physicians (PCP) screen patients at every clinical visit. Others test urine quarterly, yearly—and some, not at all. What do you think is necessary?
These are the types of questions Dr. Bill McCarberg, the moderator of Drug Testing in Pain Management, discusses with panel members and pain medicine specialists Humam Akbik, MD; Michael Clark, MD; and Howard Heit, MD.
PCPs Show Good Judgment in Clinical Practice
Primary care physicians and family practitioners show good judgment in a patient-centered approach to the treatment of patients with different diagnoses. In addition to good judgment, physicians combine objective test results and outcomes from patient observation to safeguard health and monitor compliance with a prescribed treatment plan.
Urine drug testing is an objective tool physicians use to monitor prescription opioid use by patients. The above-mentioned panel members agree UDT is an important part of the care you provide patients in chronic pain taking prescribed opioids. However, the question remains, “How frequently should you test patients?” Unfortunately, in the absence of formal guidelines, UDT frequency is your decision.
Observing the behaviors of your patients can help you determine when and how frequently you test. In particular, risky behaviors can be an indication of aberrance.
- Early refill request(s)
- Repeatedly losing medication
- Emergency department visit(s) for pain
- Taking more of the drug than prescribed
- Demanding more medication, or a higher dose to control pain
- Presenting impaired to the physician’s office
Detecting drug misuse and abuse is a challenge. A primary care provider may have many long-standing patient relationships with perceivable levels of mutual trust. The PCP may be acquainted with or provide care to members of the patient’s family. However, knowing a patient in the clinical setting is merely a snapshot in time.
Patient Risk Assessment Includes
- Clinical judgment skills
- Utilizing a risk assessment tool (eg, Opioid Risk Tool).
- Consider more frequent UDT in patients at higher risk.
- Risk assessment combined with behavioral observation.
- Testing as often as is needed to monitor opioid prescription compliance.
Substance Addiction: Should You Refer to a Specialist?
Addiction to different types of substances is relatively common in the United States (US). Tobacco is an example—over 20% of people in the US are addicted to nicotine.
Addiction is a complex disease, and a few patients in chronic pain taking prescription opioid medication develop drug addiction. The National Institute on Drug Abuse (NIDA) reported the actual percentage of patients may be 3% (and may trend higher), but quickly pointed out that the potential risks (eg, drug tolerance) are variable, and long-term studies of prescription opioid addiction are necessary.1
There are several scenarios in which a primary care physician may decide it’s in the patient’s best interest to refer to a specialist. This action typifies a patient-centered approach wherein the PCP utilizes good clinical judgment, as well as risk assessment combined with behavioral observation.
Those scenarios include:
- The risk for addiction seems too high.
- Co-existing depression
- Co-existing mental health problem
- Provide the patient alternative care beyond the PCP's scope
- Chronic Pain and Treatment and Addiction. Prescription Drugs: Abuse and Addiction. National Institute on Drug Abuse (NIDA). http://www.drugabuse.gov/publications/research-reports/prescription-drugs/chronic-pain-treatment-addiction. Updated October 2011. Accessed January 29, 2013.