Potential for Misuse
A patient's history of substance misuse doesn't absolutely preclude the use of opioid therapy. But, management of that patient should include increased monitoring and consultation with appropriate specialists.
Clinicians should screen patients both at the time of consideration of use of chronic opioid therapy and periodically during active treatment. Screening surveys may be helpful to a clinician in determining the risk of aberrant drug behaviors and guiding the frequency of monitoring. Screening surveys could be incorporated into the triage/nurse screening process prior to seeing the clinician. Screening can include surveys including but not limited to:
- the revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R)
- Brief Risk Interview (BRI)
- the Current Opioid Misuse Measure (COMM)
- the Opioid Risk Tool (ORT)
- biological screens, such as urine drug screens
- assessment of drug effects during examinations
- general alertness to other physical, emotional, and social indicators
Urine drug screens can be useful for monitoring adherence to therapy and for detecting the presence of other illicit or non-prescribed controlled substances that may point to a need for increased surveillance, consultation, and possibly discontinuation of current opioid treatment. Lab tests are also necessary to verify the presence of the prescribed opioid medication at levels that are consistent with dose and frequency in order to detect potential aberrant behavior such as diversion.
The clinician's choice of a urine drug screen needs to be consistent with the patient's pain therapy. There aren't any one-size-fits-all screens covering the entire range of opioids. The urine drug screen also needs to be consistent with drug use patterns in the community. Legal and illegal drug use patterns vary between communities. Immunoassay and gas chromatography/mass spectrometry (GC/MS) urine tests measure metabolites (for the most part) that presume to indicate the use of controlled substances. Immunoassays are usually conducted in office. A positive result from an immunoassay leads to a follow-up test with the more accurate GC/MS (usually at an outside laboratory). False positives in urine testing remain a problem, even with GC/MS tests used for confirmation. And, not all GC/MS tests are created equal; the quality of GC/MS tests varies greatly between laboratories. Special lab test orders are required for the detection of methadone, buprenorphine, and tramadol.
Specimen integrity testing and result interpretation
|Urine Specimen Integrity Test||Previous Result||Previous Interpretation||Revised Result||Revised Interpretation|
|Creatinine (mg/dL)||< 2.0||Specimen unusually dilute, suspect specimen dilution/substitution||< 2.0||Suspect specimen substitution|
|Creatinine (mg/dL)||2.0 - 19.9||Specimen unusually dilute||2.0 - 19.9||Specimen dilute|
|Creatinine (mg/dL)||20 - 200||No comment||20 - 300||Specimen normal|
|Creatinine (mg/dL)||> 200||Specimen unusually concentrated||> 300||Specimen concentrated|
|pH||< 3||Specimen unsatisfactory, abnormally low pH, suspect specimen adulteration||< 3||Specimen unsatisfactory, abnormally low pH, suspect specimen adulteration|
|pH||3 - 11||Specimen within normal limits||3 - 11||Specimen within normal limits|
|pH||> 11||Specimen unsatisfactory, abnormally high pH, suspect specimen adulteration||> 11||Specimen unsatisfactory, abnormally high pH, suspect specimen adulteration|
|General Oxidants||Negative||Specimen within normal limits||Negative||Specimen within normal limits|
|General Oxidants||Positive||Specimen unsatisfactory, presence of an oxidant detected, suspect specimen adulteration||Positive||Specimen unsatisfactory, presence of an oxidant detected, suspect specimen adulteration|
|Cannabinoids||NSAIDs, Marinol, Protonix|
|Opioids||Poppy seeds, chlorpromazine, rifampin, dextromethorphan, quinine|
|Amphetamines||Ephedrine, methylphenidate, trazodone, bupropion, desipramine, amantadine, ranitidine, phenylpropanolamine, Vicks Vapor Spray|
|PCP||Chlorpromazine, thioridazine, meperidine, dextromethorphan, diphenhydramine, doxylamine|
|Benzodiazepine||Oxaprozin (Daypro), some herbal agents|
|ETOH||Asthma inhalers (sometimes)|
Gas chromatography should confirm all positives; screening detects a presence or absence, not the concentration. Drug tests are not quantitative.
Source: Manchikanti L, et al. Protocol for accuracy of point of care (POC) or in-office urine drug testing (Immunoassay) in chronic pain patients: A prospective analysis of immunoassay and liquid chromatography tandem mass spectometry (LC/MS/MS). Pain Physician 2010; 13:E1-E22 (49).
Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician's Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 21-25.
Manchikanti, MD, Laxmaiah, et al. "Protocol for Accuracy of Point of Care (POC) or In-Office Urine Drug Testing (Immunoassay) in Chronic Pain Patients: A Prospective Analysis of Immunoassay and Liquid Chromatography Tandem Mass Spectometry (LC/MS/MS) ." [PDF - 500 KB] Pain Physician 13 (2010): E1-E22.
Jones, T., Moore, T. (2013). Preliminary Data on a New Opioid Risk Assessment Measure: The Brief Risk Interview. Journal of Opioid Management. 9 (1), 20-27.
Christo, P; Manchikanti, L; et al. "Urine Drug Testing in Chronic Pain." Pain Physician. (2011), 14: 123-143.
Melanson (etal). "Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management." Pain Med. (2013), Jul 30 (epub ahead of print).
Milone, M. "Laboratory Testing for Prescription Opioids." J Med Toxicol. (2012) 8:408-16. (Urine Drug Testing in Primary Care accessed September 18, 2013)