Drug misuse: is there something your patient isn’t telling you?
Your patient, a 56-year-old male, has come to see you complaining of lower back pain. It’s been 4 months since you prescribed hydromorphone for his pain, and up until now follow-up has been very positive: he has reported pain relief at each required monthly checkup. Now he’s back prematurely, 2 weeks before his next scheduled monthly visit.
As you make your way down the corridor to the exam room, your mind ticks off possible reasons for the therapy no longer working, including opiate tolerance. You also have your mental list of questions to ask. Among those questions should be one more, even though it doesn’t directly concern your patient’s complaint. Namely, you should probe whether your patient has been taking any other medications, even if it is something as seemingly benign as his wife’s sleeping pills on occasion. Even if he didn’t list anything on the intake form. For the startling truth is this: there’s a 50-50 chance that knowingly or unknowingly, your patient is misusing drugs.
That’s one takeaway from the new 2018 Health Trends™ report by Quest Diagnostics. According to the report—which is based on 3.9 million test results between 2011 and 2017 and is believed to be the largest report of its kind—more than half of Americans tested misused their prescription drugs in 2017.1 And opioids such as hydromorphone are in the thick of it.
Quest data show that the most frequent form of misuse is drug mixing, a contributing factor to overdose deaths that shows no signs of abating. Among patients in general care, use of non-prescribed medications and illicit drugs declined. That is good news for primary care physicians. Unfortunately, the prevalence cannot be ignored. In addition, the report also found that the highly dangerous combination of opioids and benzodiazepines is frequently detected in patients tested in primary care and pain management settings, with 1 in 5 test results showing concurrent use. Gabapentin misuse also rose sharply in just 1 year.
These findings indicate that patients in general care deserve extra vigilance given the potential to mix or otherwise misuse drugs, whether intentionally or unintentionally. According to the Centers for Disease Control and Prevention (CDC), drug overdoses killed more than 72,000 Americans in 2017, a 13 percent increase over the previous year and a twofold increase over the past decade.2
What can be done?
Given the prevalence of drug mixing and other misuse, having a clinical drug monitoring process in place could help better protect your patients and your practice. Guidelines for opioid prescribing and monitoring include the following recommendations for such a protocol3-7:
- Evaluation of risk factors for opioid-related harm such as potential for abuse, misuse, or diversion; history of substance use disorder; or concurrent benzodiazepine use
- A review of state-based Prescription Drug Monitoring Program (PDMP) database to identify controlled substances prescribed by other providers, avoid dangerous drug interactions, and identify “doctor shopping” behaviors
- Baseline urine drug monitoring (UDM) for prescribed, unprescribed, and illicit substances before starting opioid therapy and periodic UDM at least annually throughout the duration of therapy based on risk status
Studies show that urine drug testing identifies more nonadherent patients than behavioral monitoring or self-reporting alone,8 and that just the prospect of testing may deter a patient from illicit drug use.9 However, many primary care physicians are concerned with patients’ feelings about drug testing and may not feel comfortable talking to their patients about it. They worry that raising the topic may make patients feel their doctor doesn’t respect or trust them.10 They want to partner with their patients, not police them. Here are a few recommendations to help introduce drug monitoring while maintaining a trusting patient-doctor relationship10:
- When you initiate opioid therapy for chronic pain, inform the patient that routine monitoring includes baseline and possibly annual urine drug testing. State that this is normal protocol in your practice for all patients initiating chronic opioid therapy.
- Present a written agreement—a contract—in which the patient agrees to periodic drug testing upon your request. State that you both will sign this contract and it will be inserted into their medical record, reminding and reassuring them that their medical record remains confidential.
- Assure the patient that it is your practice’s experience that this arrangement works best for both patients and the practice.
- Consider urine drug testing for all patients who are on chronic opioid therapy (>30 days). Not only does this help establish a consistent protocol, but with an estimated 50% of all UDM results showing unexpected results,1 a universal protocol may detect misuse in patients who otherwise might not be showing overt signs of misuse.
Where can I find help?
Quest Diagnostics has clinical drug monitoring specialists, including toxicologists, who can advise you on setting up a clinical drug monitoring protocol for your practice, as well as which types of testing you may need. To learn more, contact your Quest representative, call 1.877.40.RXTOX (1.877.407.9869), or visit QuestDrugMonitoring.com.
1. Quest Diagnostics. Health trends: drug misuse in America 2018. September 2018.
2. National Institute on Drug Abuse. Overdose death rates. August 2018. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed October 16, 2018.
3. Centers for Disease Control and Prevention. Guideline for prescribing opioids for chronic pain: fact sheet. www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf. Accessed October 16, 2018.
4. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(12):113-130.
5. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624-1645.
6. Argoff CE, Alford DP, Fudin J, et al. Rational urine drug monitoring in patients receiving opioids for chronic pain: consensus recommendations. Pain Med. 2018;19(1):97-117.
7. Office of National Drug Control Policy. Prescription drug monitoring programs. www.ncjrs.gov/pdffiles1/ondcp/pdmp.pdf. 2011. Accessed August 3, 2018.
8. Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097-1102.
9. Nichols JH, Christenson RH, Clarke W, et al. Executive summary. The National Academy of Clinical Biochemistry Laboratory Medicine Practice Guideline: evidence-based practice for point-of-care testing. Clin Chim Acta. 2007;379(1-2):14-28.
10. Adapted from Sarah McBane S and Weigle N. Is it time to drug test your chronic pain patient? J Fam Pract. 2010 November;59(11).