Urine Drug Testing (UDT) in Pain Management. Nov 27, 2017

Transcription

1 Urine Drug Testing (UDT) in Pain Management Nov 27, 2017

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Learning Objectives How and when to use urine drug testing (UDT) as part of a comprehensive management plan when prescribing opioids for chronic non-cancer pain Discuss how to manage unexpected UDT results

4 Urine Drug Testing (UDT) Management tool for patients treated with controlled substances or at risk for substance use May use UDT as an option for assessment and should be aware of benefits and limitations, appropriate test ordering and interpretation, and have a plan to use results

5 Prior to UDT Inform the patient Take careful history of medication/drug use in the past week Collect the sample in physicians office; ensure proper labelling

6 Point of Care Testing Rapid test performed in clinic e.g. urine dipsticks, cups Immunoassay drug screens are designed to classify substances as either present or absent according to a predetermined cut-off threshold When the amount of drug in the urine sample is equal to or exceeds the cut off concentration of a particular device, the outcome is a positive result POINT OF CARE (POC) LABORATORY TESTING COMPARISON

7 Laboratory Testing Specimen sent to laboratory Gas or Liquid Chromatography/ Mass Spectrometry is a more definitive laboratory based procedure to identify specific drug and/or metabolites and is needed in 3 instances: To specifically identify the drug; for example, that morphine is the opiate causing the positive immunoassay response To identify drugs not otherwise included in other testing To contest results disputed by the patient POINT OF CARE (POC) LABORATORY TESTING COMPARISON

8 Comparison - ADVANTAGES Point of Care -Immunoassay Rapid Results Concurrently test for multiple drug classes Very responsive for morphine and codeine Laboratory - Chromatography Identifies specific drug Confirmation of results More accurate for semisynthetic and synthetic opioids Does not cross react with poppy seeds POINT OF CARE (POC) LABORATORY TESTING COMPARISON

9 Validation Patients may tamper with urine samples to hide aberrant behaviours by: adding adulterants diluting the sample substituting another individuals sample for their own ingesting excessive water or diuretics prior to giving a sample Tests performed to improve the reliability of urine sample results NORMAL CHARACTERISTICS OF A URINE SPECIMEN Temperature (within 4 mins) Degrees Celcius ph Urinary Creatinine >20 mg/dl Specific Gravity >1.003

10 What To Do With Abnormal UDT Results: General Approach Take careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory (potential for false positive and false negative) Check with lab re: potential error What kind of urine test was done? Interpret results in the context of the patient s clinical presentation and assessments Possibly ask the lab to re-run the sample with chromotgraphy if response still unclear UDT, urine drug test.

11 Unexpected Results Case Table of Contents Is the patient taking the opioid I prescribed? I didn t prescribe that! I didn t expect to find that in your urine sample!

12 Unexpected Results Case 1 Is the patient taking the opioid I prescribed?

13 John 39 year old male Currently taking CR oxycodone resistant to crushing 40 mg q12h for chronic back pain On duloxetine 60 mg daily for some neuropathic features with effect Using some quetiapine 25 qhs to sleep ORT score: 8 1 for age 4 for use of THC in college, enough that he failed a semester, then righted himself and graduated, now denies using any 3 for Dad having an alcohol problem; folks split up when he was young due to it.

14 14

15 You do a routine urine on visit today Shows THC Negative for oxycodone, TCAs, benzodiazepines Now what do you do?

16 Would you? A) Fire him as he is lying to you? B) Tell him that you can no longer prescribe opioids as he is not taking them anyways? C) Confront him about the THC? D) Check when he last took CR oxycodone resistant to crushing? E) Call the lab to check the results? Take careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory

17 Available at: Interpreting Unexpected Results of Urine Drug Screens Unexpected Result UDS negative for prescribed opioid Possible Explanations False negative Non-compliance Diversion Actions for the Physician Table B-3.1 Repeat test using chromatography; specify the drug of interest (e.g. oxycodone often missed by immunoassay) Take a detailed history of the patient s medication use for the preceding 7 days (e.g. could learn that patient ran out several days prior to test) Ask patient if they ve given the drug to others Monitor compliance with pill counts

18 John Restarted marijuana use and problems at work and home Financial issue selling CR oxycodone and some quetiapine CR oxycodone discontinued (should this be tapered?) Quetiapine prescribing decreased to 7days supply Offered resources for drug counselling and treatment programs Revised ORT score - High Risk Regular and random UDT

19 Unexpected Results Case 2 I didn t prescribe that!

20 Mary 66 year old female Spinal stenosis 2 failed surgeries in 1999 and 2006 Intolerant of NSAIDS/ COX-2 No personal of family history of drugs or alcohol No history of mental health issues

21 Mary Has taken acetaminophen 650 QID on a regular basis Reports constipation with acetaminophen/codeine 30mg (not filled Rx in 1 year) Reports significantly decreased QoL over last 6 months After exhausting more physical and psychological modalities, you are considering a trial of oxycodone 5mg

22 Mary Baseline UDT recommendation roadmap Do this on everyone UDS immunoassay is positive for benzodiazepines and opioids

23 Mary Now what do you do? Take careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory

24 Available at: Interpreting Unexpected Results of Urine Drug Screens Table B-3.1 Unexpected Result Possible Explanations Actions for the Physician UDS positive for nonprescribed opioid or benzodiazepines False positive. Patient acquired opioids from other sources (doubledoctoring, street ) Repeat UDS regularly Ask the patient if they accessed opioids from other sources Assess for opioid misuse/addiction (See Guideline, Part B, Recommendation 12) Review/revise treatment agreement

25 Known Agents To Cause Interference in Urine Drug Test Results Opioids Marijuana Cocaine Amphetamines Benzodiazepines Dextromethorphan Diphenhydramine (methadone assay only) Poppy seeds Quinine Quinolone antibiotics Rifampin Verapamil (methadone assay only) Efavirenz Hemp seed NSAIDs PPIs Tolmetin Coca leaf tea Amantadine Bupropion Chlorpromazine Desipramine Labetalol Methylphenidate Phentermine Phenylephrine Pseudoephedrine Ranitidine Selegiline Tolmetin Trazodone Typical antipsychotics Oxaprozin Sertraline NSAID, non-steroidal anti-inflammatory drug. PPI, proton pump inhibitor. Adapted from Peppin JF, et al. Pain Med 2012;13: , Reisfield et al Ann Clin Lab Med 1997, Piergies et al Arch Path Lab Med 1997

26 Mary Explanation of Mary's results: Benzodiazepines: Occasionally takes her sisters diazepam 5mg pills Uses acetaminophen/codeine 8mg on a regular basis (up to 8 per day)

27 Mary Explanation of Mary's results: Benzodiazepines: Diazepam metabolizes to nordiazepam, temazepam and oxazepam. Opioids Codeine metabolizes to morphine

28 Benzodiazepines and Opioids Increases the risk of sedation, overdose, and diminished function in all patients, especially as age advances Benzodiazepines increase opioid toxicity and risk of overdose Canadian Guideline for Safe and Effective Use of Opioids for CNCP Part B

29 Mary The presence of a substance that we are not expecting to find can be used to educate patients on safety of drug interactions and toxicity Mary was counseled on the danger of acetaminophen toxicity and use of benzodiazepines Additional counseling points: Definition of misuse Information on safe storage, no sharing, safe disposal, etc. Opioid Treatment Agreement

30 Mary Treatment Plan Not start oxycodone prescriptions for now Explore reasons for benzodiazepine use and possible nonbenzodiazepine treatments for this (medication, psychological, behavioural) Repeat urine test in 3-4 weeks to ensure benzodiazepines are now negative (diazepam can remain positive for 3 weeks) Ensure Mary's daily acetaminophen intake is below a level of concern

31 Unexpected Results Case 3 I didn t expect to find that in your urine sample!

32 Frank 34 year old male C6-7 fracture from snowmobile accident subsequent fusion C5 to T1 PMHx ADD SHx Recently separated with 2 children Smoker 1 ppd ETOH max 3 per day and 15 per week Denies street drug use FHx mental illness - ADD

33 Frank Meds Oxycodone-acetaminophen 1-2 Q4h PRN 8 per day Meloxicam 15mg PO Qdaily Tx No change with physio, chiro, acupuncture VAS Neck pain 8/10 radiating to trapezius and shoulder bilaterally

34 Frank CAGE-AID Low Risk Opioid Risk Tool 4/7 moderate risk Male age Hx of ADD 2 Current depression 1

35 Assessment UDS immunoassay in office Opiates EDDP Oxycodone Cocaine TCA - negative negative positive positive negative Now what do you do? Take careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory

36 Available at: Interpreting Unexpected Results of Urine Drug Screens Table B-3.1 Unexpected Result Possible Explanations Actions for the Physician UDS positive for illicit drugs (e.g. cocaine, cannabis) False positive Patient is occasional user or addicted to the illicit drug Cannabis is positive for patients THC:CBD (Sativex ) or using medical marijuana Repeat UDS regularly Assess for abuse/addiction and refer for addiction treatment as appropriate Ask about medical prescription of THC:CBD or medical marijuana access program

37 Known Agents To Cause Interference in Urine Drug Test Results Opioids Marijuana Cocaine Amphetamines Benzodiazepines Dextromethorphan Diphenhydramine (methadone assay only) Poppy seeds Quinine Quinolone antibiotics Rifampin Verapamil (methadone assay only) Efavirenz Hemp seed NSAIDs PPIs Tolmetin Coca leaf tea Amantadine Bupropion Chlorpromazine Desipramine Labetalol Methylphenidate Phentermine Phenylephrine Pseudoephedrine Ranitidine Selegiline Tolmetin Trazodone Typical antipsychotics Oxaprozin Sertraline NSAID, non-steroidal anti-inflammatory drug. PPI, proton pump inhibitor. Adapted from Peppin JF, et al. Pain Med 2012;13: , Reisfield et al Ann Clin Lab Med 1997, Piergies et al Arch Path Lab Med 1997

38 Frank Admitted to cocaine use intermittently Offered resources for drug counselling and treatment programs Revised ORT score - High Risk Regular and random UDT Treated with non opioid pharmaceuticals and modalities; or Structured opioid treatment with tight boundaries

39 Random UDTs When a patient steps out of bounds Explain need for good communication system patient cell # or answering system After seeing pt, choose some random dates and record on chart Receptionist writes down in a daily TO-DO list and calls pt by 10:00am to come in Patient has 24hrs to comply or violation

40 What if? He does not admit to the use? Denies it vehemently? Gets angry and defensive? What are your next options?

41 Summary UDS is a recommendation in The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain UDS point of care immunoassay and laboratory chromatography have different advantages/disadvantages and limitations Your first action with an unexpected result should be Take careful history of medication/drug use in the past week and discuss openly with the patient without being accusatory Each type of unexpected result has a DDx and appropriate physician actions