Pain Physician. 2017 Feb;20(2S):S135-S145.

Repeated Quantitative Urine Toxicology Analysis May Improve Chronic Pain Patient Compliance with Opioid Therapy.

Knezevic NN1, Khan OM2, Beiranvand A2, Candido KD.

1 Vice Chair for Research and Education, Department of Anesthesiology and Pain Management, Advocate Illinois Masonic Medical Center, Clinical Associate Professor of Anesthesiology and Surgery at University of Illinois, Chicago, IL.

2 Dept. of Anesthesiology, Advocate Illinois Masonic Medical Center.

Abstract

BACKGROUND:

Even though serious efforts have been undertaken by different medical societies to reduce opioid use for treating chronic benign pain, many Americans continue to seek pain relief through opioid consumption. Assuring compliance of these patients may be a difficult aspect of proper management even with regular behavioral monitoring.

OBJECTIVE:

The purpose of this study was to accurately assess the compliance of chronic opioid-consuming patients in an outpatient setting and evaluate if utilizing repeated urine drug testing (UDT) could improve compliance.

STUDY DESIGN:

Retrospective analysis of prospectively collected data.

SETTING:

Outpatient pain management clinic.

METHODS:

After Institutional Review Board (IRB) approval, a retrospective analysis of data for 500 patients was conducted. We included patients who were aged 18 years and older who were treated with opioid analgesic medication for chronic pain. Patients were asked to provide supervised urine toxicology specimens during their regular clinic visits, and were asked to do so without prior notification. The specimens were sent to an external laboratory for quantitative testing using liquid chromatography-tandem mass spectrometry.

RESULTS:

Three hundred and eighty-six (77.2%) patients were compliant with prescribed medications and did not use any illicit drugs or undeclared medications. Forty-one (8.2%) patients tested positive for opioid medication(s) that were not prescribed in our clinic; 8 (1.6%) of the patients were positive for medication that was not prescribed by any physician and was not present in the Illinois Prescription Monitoring Program; 5 (1%) patients tested negative for prescribed opioids; and 60 (12%) patients were positive for illicit drugs (8.6% marijuana, 3.2% cocaine, 0.2% heroin). Repeated UDTs following education and disclosure, showed 49 of the 77 patients (63.6%) had improved compliance.

LIMITATIONS:

This was a single-site study and we normalized concentrations of opioids in urine with creatinine levels while specific gravity normalization was not used.

CONCLUSIONS:

Our results showed that repeated UDT can improve compliance of patients on opioid medications and can improve overall pain management. We believe UDT testing should be used as an important adjunctive tool to help guide clinical decision-making regarding opioid therapy, potentially increasing future quality of care.Key words: Urine toxicology analysis, chronic pain, opioids, compliance, pain management, urine drug testing, urine drug screening.

PMID: 28226335

 

Supplement:

Opioid therapy has shown to be effective in chronic pain patients in short-term use, with a growing concern of dependency and potential for abuse with long-term use (1). The population of chronic pain patients grows every year and contributes to massive healthcare costs, decreased quality of life, and lost productivity (2,3). With a growing number of people dealing with an opioid use disorder while opioid overdose deaths exceeding overdose deaths of cocaine and heroin combined (4), there is a growing concern for compliance for patients who are prescribed opioid medication. Data has shown that self-reporting is not reliable and patients with an opioid use disorder may not be honest in self-reporting (5,6). Opioid guidelines were recently published by the Center for Disease Control (CDC) and urine toxicology has been recognized to play an important role in identifying use and misuse of opioid medications (7).  Our recent publication investigated whether compliance can be improved in chronic pain patients taking opioid medication by conducting repeated quantitative urine toxicology tests.

In our study, we conducted repeated urine toxicology tests on a group of 500 chronic non-cancer pain patients. Prior to opioid therapy all patients were required to sign our treatment agreement contract which requires the patient’s compliance. We considered the patient to be compliant if their urine toxicology results were positive only for the medications that was prescribed. Patients were considered non-compliant if there was no detection of prescribed medication, positive detection for medication that our clinic did not prescribe, or detection of illicit drugs. Patients who were prescribed opioid medication were then asked during their clinic visits, without any prior knowledge, to provide urine samples. These samples were then analyzed at a laboratory and were tested for presence or absence of medications as well as illicit drugs. During our study, we also cross-referenced the patient’s chart as well as the Illinois Prescription Monitoring Program to ensure that the patient wasn’t being prescribed opioid medications by any other clinician. Urine toxicology testing was then repeated randomly for any patients that were non-compliant. If any repeated tests were positive for illicit drugs, opioid medication was tapered and discontinued and the patient was limited to only interventional procedures.

 

The most commonly prescribed opioid medications and percentages of patients taking them are provided in (Table 1).

 

Table 1: Percentage for opioid medication use

*Some of our patients were using multiple medications for chronic pain so total percentage is > 100%

 

Out of 500 patients, 270 of them were female and 230 were male. Several forms of chronic pain were treated, the most common being lower back pain, which included 65% of our patients. The second most common complaint was for arthritis, joint, and musculoskeletal pain at 24.7%, while the third most common complaint was cervical spondylosis pain 7.8%. Other complaints included headache, myalgia, and Complex Regional Pain Syndrome (CRPS). Our results showed there was no difference between the type of pain and difference of sex, but there was a significant difference between opioid dosage and sex. Male patients were using higher dosage opioid 38.86 mg ± 70.73 mg morphine equivalents compared to female patients at 23.32 mg ± 43.13 mg morphine equivalents.

Our results showed that 77.2% of our patients were compliant with opioid medication that was prescribed by our physicians. Of the 500 patients, 8.6% were positive for marijuana and 8.2% were taking medication that was prescribed by other clinicians or hospitals. Cocaine and heroin were present in 3.4% of patients, while 1.6% were positive for medication that was not prescribed by our clinicians or present in the Illinois Prescription Monitoring Program. Also, one percent of our patients were negative for prescribed medication (Table 2).

 

Table 2: Patient’s Compliance

 

Patients were then counseled and the results of the urine tests were explained. We repeated the urine tests on 77 of the 97 non-compliant patients. Results of repeated urine drug tests showed that 63.6% of patients had improved their compliance, and improvement rate was the same between men and women.

Results of our study have shown that urine toxicology testing is an important assistive tool aside from self-reporting questionnaires, review of medical charts, behavioral observation, and cross-referencing the prescription monitoring program. With urine toxicology testing there exists a concern of over-utilization of tests and overbilling. Within our practice we suggest repeating tests 2-4 times per year for compliant patients which can be further determined by the physician on case-by-case basis. Previous studies on urine drug testing have shown that it can be a tool to identify misuse of prescribed medication. However, our results have shown that repeated testing can also improve compliance and overall pain management of patients. We believe that this method should be utilized not only by pain physicians but also by primary care physicians as it has been shown that 40% of primary care visits present with chronic pain (8).

 

 

 

Picture 1. The authors (left to right): Nebojsa Nick Knezevic, MD, PhD, Afsaneh Beiranvand, MD, Omar M. Khan, MD, Kenneth D. Candido, MD

 

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7) Center for Disease Control and Prevention – CDC Guideline for Prescribing Opioids for Chronic Pain: www.cdc.gov/ mmwr/volumes/65/rr/rr6501e1.htm

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