scholarly journals Reducing Opioid Analgesic Deaths in America: What Health Providers Can Do

2015 ◽  
Vol 3;18 (3;5) ◽  
pp. E307-E322 ◽  
Author(s):  
Taghogho Agarin
Keyword(s):  
Health Care Providers ◽  
Associated Factors ◽  
Drug Testing ◽  
Opioid Analgesic ◽  
Health Providers ◽  
Care Providers ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
High Doses

Background: Available data have shown steady increases of drug overdose deaths between 1992 and 2011. We review evidenced-based recommendations provided by a few prominent North American pain societies and suggest ways on how health providers might help reduce opioid analgesic deaths by implementing these practices. Objective: To identify health care providers’ roles in reducing opioid analgesic deaths. Study Design: A comprehensive review of current literature. Methods: The review included relevant literature identified through searches of MEDLINE, Cochran reviews, and Google Scholar, PubMed and EMBASE from January 1998 to January 2014. The level of evidence was classified as I (good), II (fair), and III (limited) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Results: Several practices such as too high doses overall, giving too high doses to opioid naive patients, too fast opioid titration, insufficient use and knowledge of urine drug testing, not updating knowledge of drug metabolism/interactions, and inadequate patient monitoring are associated with higher risks of opioid analgesic deaths. Suboptimal risk stratification of patients, rotation practices, and use of opioids analgesics in chronic noncancer pain are also associated factors. Limitations: There were a paucity of good evidence studies which show recommendations reduce death. Conclusion: Providers should be aware of all associated factors with opiate analgesic deaths and apply the available evidence in reducing opioid analgesic deaths. Key words: Opioid analgesic deaths, methadone deaths, opioid mortality, opioid guidelines, genetic testing for opioids, urine drug testing

scholarly journals Lower Cutoffs for LC-MS/MS Urine Drug Testing Indicates Better Patient Compliance

2017 ◽  
Vol 7 (20;7) ◽  
pp. E1107-E1113
Author(s):  
Kevin Krock
Keyword(s):  
Health Care Providers ◽  
Drug Testing ◽  
Illicit Drugs ◽  
Patient Adherence ◽  
False Negative ◽  
Test Results ◽  
Care Providers ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Cutoff Levels

Background: Urine drug testing is used by health care providers to determine a patient’s compliance to their prescribed regimen and to detect non-prescribed medications and illicit drugs. However, the cutoff levels used by clinical labs are often arbitrarily set and may not reflect the urine drug concentrations of compliant patients. Objectives: Our aim was to test the hypothesis that commonly used cutoffs for many prescribed and illicit drugs were set too high, and methods using these cutoffs may yield a considerable number of false-negative results. The goals of this study were to outline the way to analyze patient results and estimate a more appropriate cutoff, develop and validate a high sensitivity analytical method capable of quantitating drugs and metabolites at lower than the commonly used cutoffs, and determine the number of true positive results that would have been missed when using the common cutoffs. Study Design: This was a retrospective study of urine specimens submitted for urine drug testing as part of the monitoring of prescription drug compliance described in chronic opioid therapy treatment guidelines. Setting: The study was set in a clinical toxicology laboratory, using specimens submitted for routine analysis by health care providers in the normal course of business. Methods: Lognormal distributions of test results were generated and fitted with a trendline to estimate the required cutoff level necessary to capture the normal distributions of each drug for the patient population study. A validated laboratory derived liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis capable of achieving the required cutoff levels was developed for each drug and/or metabolite. Results: The study shows that a lognormal distribution of patient urine test results fitted with a trendline is appropriate for estimating the required cutoff levels needed to assess medication adherence. The study showed a wide variation in the false-negative rate, ranging from 1.5% to 94.3% across a range of prescribed and illicit drugs. Limitations: The patient specimens were largely sourced from patients in either a long-term pain management program or in treatment for substance use disorder in the US. These specimens may not be representative of patients in other types of treatment or in countries with different approaches to these issues. Conclusions: The high-sensitivity method reduces false-negative results which could negatively impact patient care. Clinicians using less sensitive methods for detecting and quantifying drugs and metabolites in urine should exercise caution in assessing patient adherence using and changing the treatment plan based on those results. Key words: Urine drug testing, patient adherence, clinical toxicology, immunoassay, LC-MS, definitive drug testing, REMS, negative test results, false negative

scholarly journals Interpretation and Utility of Drug of Abuse Screening Immunoassays: Insights From Laboratory Drug Testing Proficiency Surveys

2019 ◽  
Vol 144 (2) ◽  
pp. 177-184 ◽  
Author(s):  
Matthew D. Krasowski ◽  
Gwendolyn A. McMillin ◽  
Stacy E. F. Melanson ◽  
Annabel Dizon ◽  
Barbarajean Magnani ◽  
...  
Keyword(s):  
Health Care Providers ◽  
Drug Testing ◽  
Cross Reactivity ◽  
Prescription Drug Abuse ◽  
Variable Cross ◽  
Care Providers ◽  
Synthetic Opioids ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Abused Drugs

Context.— Urine drug testing is frequently ordered by health care providers. Immunoassays are widely used for drug testing, yet have potential limitations, including variable cross-reactivity. The last decade has seen worsening of a prescription drug abuse epidemic. Objective.— To use data from a College of American Pathologists proficiency testing survey, Urine Drug Testing, Screening, to determine and summarize the characteristics, performance, and limitations of immunoassays. Design.— Seven years of proficiency surveys were reviewed (2011–2017). Results.— Rapid growth was seen in participant volumes for specific immunoassays for synthetic opioids (eg, buprenorphine, fentanyl, oxycodone) and 3,4-methylenedioxymethamphetamine (“ecstasy”). Participant volumes remained high for immunoassays targeting less commonly abused drugs such as barbiturates and phencyclidine. For opiate immunoassays, the number of laboratories using a 2000 ng/mL positive cutoff remained stable, and an increasing number adopted a 100 ng/mL cutoff. Opiate and amphetamine immunoassays showed high variability in cross-reactivity for drugs other than the assay calibrator. Assays targeting a single drug or metabolite generally performed well on drug challenges. Conclusions.— Survey results indicate strong clinical interest in urine drug testing and some adoption of new assays. However, urine drug testing availability does not parallel prevailing patterns of drug prescribing and abuse patterns. In particular, specific immunoassays for synthetic opioids and a lower positive cutoff for opiate immunoassays may be underused, whereas immunoassays for barbiturates, methadone, propoxyphene, and phencyclidine may be overused. Laboratories are encouraged to review their test menu, cutoffs, and assay performance and adjust their test offerings based on clinical needs and technical capabilities.

Systematic urine drug testing for detecting and managing opioid misuse among chronic noncancer pain patients in primary care—The HARMS Program: A retrospective chart review of 77 patients

2020 ◽  
Vol 16 (4) ◽  
pp. 277-282
Author(s):  
Niharika Shahi, HBSc ◽  
Ryan Patchett-Marble, BSc, MD, CCFP(AM)
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Drug Testing ◽  
Chart Review ◽  
Retrospective Chart Review ◽  
Opioid Misuse ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain

The prevalence of opioid abuse has reached an epidemic level. National guidelines recommend safer opioid prescribing practices, including potentially monitoring patients with urine drug testing (UDT). There is limited research evidence surrounding the use of UDT in the context of chronic noncancer pain (CNCP). We evaluated the efficacy of systematic, randomized UDT to detect and manage opioid misuse among patients with CNCP in primary care. The Marathon Family Health Team (MFHT) designed and implemented a clinic-wide, randomized UDT program called the HARMS (High-yield Approach to Risk Mitigation and Safety) Program. This retrospective chart review includes 77 CNCP patients being prescribed opioids, who were initially stratified by their prescriber as “low-risk.” Each month, 10 percent of patients were selected for a random UDT with double testing (immunoassay and liquid chromatography-mass spectrometry). The primary outcome measure was UDT leading to a change in management plan. Of the 77 patients in the study, 55 (71 percent) completed at least one UDT during the 12-month study period. Overall, 22 patients had aberrant results. UDT led directly to changes in management in 15 of those patients. Four of those 15 patients were escalated to an addictions program, two were tapered from opioids with informed discussion, and nine were escalated to the high-risk monitoring stream. The results of this study show that in low-risk CNCP patients prescribed opioids, applying systematic UDT in a primary care setting is effective for detecting high risk behaviors and addiction, and altering management. Further research is needed with larger numbers using a prospective study design.

scholarly journals Urine Drug Testing in the Treatment of Chronic Noncancer Pain in a Kentucky Private Neuroscience Practice: The Potential Effect of Medicare Benefit Changes in Kentucky

2010 ◽  
Vol 2;13 (1;2) ◽  
pp. 187-194 ◽  
Author(s):  
John W. Gilbert
Keyword(s):  
Drug Abuse ◽  
Pain Management ◽  
Behavioral Health ◽  
Outcome Measures ◽  
Drug Testing ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain ◽  
Management Services

Background: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. Study Design: A retrospective review of urine drug testing services. Objective: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. Methods: An audit of services provided during 2007 was conducted using computer software. Outcome Measures: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. Results: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/ or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. Limitations: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. Conclusion: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician’s toolbox, the physician’s ability to accurately diagnose and treat these patients could be impaired. Key words: Chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

Opioid tolerance and urine drug testing among initiates of extended-release or long-acting opioids in Food and Drug Administration's Sentinel System

2017 ◽  
Vol 13 (5) ◽  
pp. 315 ◽  
Author(s):  
Marc R. Larochelle, MD, MPH ◽  
Noelle M. Cocoros, DSc, MPH ◽  
Jennifer Popovic, DVM, MA ◽  
Elizabeth C. Dee, MPH ◽  
Cynthia Kornegay, PhD ◽  
...  
Keyword(s):  
Drug Testing ◽  
Extended Release ◽  
Opioid Analgesic ◽  
Opioid Analgesics ◽  
Opioid Tolerance ◽  
Transdermal Fentanyl ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Long Acting ◽  
Tolerance Criteria

Objective: A risk evaluation and mitigation strategy for extended-release and long-acting (ER/LA) opioid analgesics was approved by the Food and Drug Administration in 2012. Our objective was to assess frequency of opioid tolerance and urine drug testing for individuals initiating ER/LA opioid analgesics.Design: Retrospective cohort study.Setting: Sentinel, a distributed database with electronic healthcare data on >190 million predominantly commercially insured members.Patients, participants: Members under age 65 initiating ER/LA opioid analgesics between January 2009 and December 2013.Main outcome measure(s): We examined the proportion of opioid-tolerantonly ER/LA opioid analgesic initiates meeting tolerance criteria: receipt of ≥30 mg oxycodone equivalents per day in 7 days prior to the first opioid-tolerant-only dispensing. We separately examined the proportion of new users of extended-release oxycodone (ERO) and other ER/LA opioid analgesics with a claim for a urine drug test in the 30 days prior to, and separately for the 183 days after, dispensing.Results: We identified 79,824 ERO, 7,343 extended-release hydromorphone, and 91,778 transdermal fentanyl opioid-tolerant-only episodes. Tolerance criteria were met in 64 percent of ERO, 64 percent of extended-release hydromorphone and 40 percent of transdermal fentanyl episodes. We identified 210,581 incident ERO and 311,660 other ER/LA opioid analgesic episodes. Use of urine drug testing for ERO compared with other ER/LA opioid analgesics was: 4 percent vs 14 percent respectively in the 30 days prior to initiation and 9 percent vs 23 percent respectively in the 183 days following initiation.Conclusions: These results suggest potential areas for improving appropriate ER/LA opioid analgesic prescribing practices.

scholarly journals Importance of Urine Drug Testing in the Treatment of Chronic Noncancer Pain: Implications of Recent Medicare Policy Changes in Kentucky

2010 ◽  
Vol 2;13 (1;2) ◽  
pp. 167-186
Author(s):  
John W. John W.
Keyword(s):  
Chronic Pain ◽  
Drug Abuse ◽  
Prescription Drug ◽  
Drug Testing ◽  
Diagnosis And Treatment ◽  
Drug Misuse ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain

Background: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. Objective: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. Discussion: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. Conclusion: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse. Key words: chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

scholarly journals Dose Dependent Urine Concentrations of Gabapentin (Neurontin®)

2020 ◽  
Vol 5 (1) ◽  
Keyword(s):  
Drug Testing ◽  
Concentration Data ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Urine Concentrations ◽  
Low Toxicity ◽  
High Doses ◽  
Dose Dependent ◽  
Positive Results ◽  
Urine Specimens

Gabapentin (Neurontin®) is frequently prescribed for a number of conditions including adjunctive therapy for partial seizures and neuropathic pain. Gabapentin is unique to most drugs in that it is titrated quickly to high doses (1,800-3,600mg/day or greater) due to its low toxicity. It is not metabolized but excreted primarily unchanged in the urine at extremely high levels ranging from 5µg/ml to >30,000µg/ml. The work reported here looks at gabapentin urine drug testing (UDT) results from 6 months of clinical urine specimens in which gabapentin was detected (n=35,526), prescribed (n=23,432, 66%) or not prescribed (n=12,094, 34%). In the prescribed population, gabapentin was primarily prescribed to females (61%). The overall age for positive results ranged from 14 to 97 years with an average age of 56.5 years. Interestingly, the average age of those patients positive for gabapentin without a prescription and positive for any illicit was 42.7 years. These data indicate that at a maximum, 34% of the total gabapentin positive samples are from abuse (no prescription). Attempts at normalization and transformation of drug concentration data using creatinine normalization did lead to a near Gaussian distribution where +/- 3 standard deviations may be estimated. It remains difficult to determine if a patient is abusing the drug when the UDT values are extremely high for patients prescribed gabapentin.

scholarly journals Interpretation of Urine Drug Testing Results in Patients Using Transdermal Buprenorphine Preparations for the Treatment of Chronic Noncancer Pain: Table 1

Pain Medicine ◽  
2015 ◽  
Vol 16 (6) ◽  
pp. 1132-1136 ◽  
Author(s):  
John D. Markman ◽  
William A. Barbosa ◽  
Jennifer S. Gewandter ◽  
Maria Frazer ◽  
Shirley Rast ◽  
...  
Keyword(s):  
Drug Testing ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain

scholarly journals Client satisfaction with existing postnatal care and associated factors: A study among mothers in Awi Zone, Amhara region, Ethiopia

2020 ◽  
Vol 16 ◽  
pp. 174550652097601
Author(s):  
Daniel Adane ◽  
Biresaw Wassihun
Keyword(s):  
Antenatal Care ◽  
Health Care Providers ◽  
Postnatal Care ◽  
Associated Factors ◽  
Client Satisfaction ◽  
Post Partum ◽  
Care Providers ◽  
Amhara Region ◽  
Awi Zone

Background: The majority of maternal and neonatal adverse events take place during the postnatal period. However, it is the most neglected period for the provision of quality care. Objective: The aim of this study among mothers in the Awi Zone, Amhara region, Ethiopia, was to assess client satisfaction with existing postnatal care and associated factors. Methods: An institution-based cross-sectional study was conducted in Awi Zone hospitals from 1 to 30 April 2018. A total of 422 post-partum mothers were selected by systematic sampling. The data were collected using a pre-tested structured questionnaire via a face-to-face interview. Data entry and analysis were completed using EpiData version 3.1 and SPSS version 22, respectively. The data were summarized with frequency and cross-tabulation. Both binary and multiple logistic regressions were used to identify predictor variables using odds ratios and 95% confidence intervals. Result: The prevalence of postnatal care satisfaction was 63%. Being from urban area (AOR = 2.1, 95% CI = (1.11–3.99)), having a history of antenatal care follow up (AOR = 1.62, 95% CI = (1.23–1.64)), spontaneous vaginal birth (AOR = 3.14, 95% CI = (1.77–3.28)), and those who did not face any complications during birth (AOR = 2.90, 95% CI = (1.47–1.69)) were some of the factors associated with client satisfaction. Conclusion: According to the results of this study, the majority of mothers were satisfied with post-partum care services. The study findings indicate that maternal satisfaction on post-partum care is mainly affected by residency, antenatal care follow up, mode of delivery, and complications during birth. Therefore, health care providers and other concerned bodies should give special attention to those mothers who are from rural areas, who face complications during birth or who have instrumental-assisted or cesarean section birth. Also, every pregnant mother should be supported to have at least four regular antenatal care visits.

Sign in / Sign up

Export Citation Format

Share Document