Efforts to treat pain more aggressively started in the 1990s and reached full stride around 2000, when even the U.S. Congress proclaimed the years 2000-2010 the Decade of Pain Control and Research.1 Unfortunately, this well-intended goal became a marketing opportunity by the opioid pharmaceutical industry, which was championed by various "thought leaders."
During the past decade, there has been an exponential increase in prescription drug-related accidental lethal drug overdoses (Figure 1). The rate of prescription abuse, misuse, and deaths grew in parallel with the sales of opioid medications.2 Prescription drug deaths now exceed deaths from motor vehicle accidents (MVA). MVAs were the previous number one cause of preventable injury deaths.3 Some of the industry thought leaders are retracting their original position on opioid therapy.4
Chronic opioid therapy (COT) is an increasingly controversial treatment without any long-term evidence to support its use.5,6 More than 50% of the deaths involved mixtures of CNS depressants.7
Urine Drug Testing
Recent studies examining Urine drug testing (UDT) suggest that the rate of aberrant drug taking behaviors and inaccurate self-report of drug use in the chronic pain clinic setting is both unreliable and problematic.8-17 (Table 1).
Several strategies hold the potential to reduce these preventable drug related deaths.18,19 UDT is one of the cornerstones to combat the prescription drug epidemic.
POC Testing Using EIA
In office point-of-care testing (POC) using enzyme immunoassay technology (EIA) was designed for pre-employment screening and other less critical uses.
POC testing has high cutoff levels that makes it prone to false negative results, and because of the EIA methodology, is prone to cross-reactivity with a host of compounds that are not of interest.
Another problem with POC testing is that POC testing provides class-specific but not drug-specific results. For example, POC will provide positive or negative results for the opioid class but not distinguish the difference between hydrocodone and codeine. One of these drugs may be prescribed but the other drug may represent an aberrant drug taking behavior. A pain management clinic must have greater detail of the precise drugs in their patients' urine to make reliable clinical decisions. Thus, POC testing lacks the necessary properties to be useful in a pain management setting.18
UDT Using Mass Spectroscopy
Therefore, UDT using confirmatory mass spectroscopy (MS) is essential. MS is not subject to the false negative and positive limitations of EIA technology. MS results are drug-specific and very sensitive. While liquid versus gas chromatography has advantages and disadvantages depending on the class of drug being detected, MS is the detection device of choice. Triple quadrupole mass spectrometer is the industry standard at this time.
When a clinician is prescribing controlled substances, appropriate use of MS-confirmed UDT has become a standard of care issue and has the potential to identify aberrant drug taking and hopefully reduce the epidemic of prescription related accidental drug overdose deaths.
1. CDC Grand Rounds: Prescription drug overdoses- a U.S. Epidemic. Morbidity and Mortality Weekly. 2012;61(01):10-13.
2. CDC: Vital Signs: Overdoses of prescription opioid pain relievers- United States 1999-2008. Morbidity and Mortality Weekly. 2011;60(43):1487-1492.
3. Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980-2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm
4. Physicians for responsible opioid prescribing. http://www.youtube.com/watch?v=QYWykvy3xDI
5. Manchikanti L, Abdi S, Atluri S, Balog CC, et al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-cancer Pain: Part I- Evidence Assessment. Pain Physician. 15:S1-S66; 2012. http://www.painphysicianjournal.com/pastissue_vw.php?jcode=68
6. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
7. CDC: Policy Impact: Prescription Painkiller Overdoses. http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
8. Michna E, Jamison RN, Pham LD, Ross EL, Janfaza D, Nedeljkovic SS, Narang S, Palombi D, Wasan AD. Urine toxicology screening among chronic pain patients on opioid therapy: Frequency and predictability of abnormal findings. Clin J Pain 2007; 23:173-179.
9. Manchikanti L, Damron KA, McManus CD, Barnhill RC. Patterns of illicit drug use and opioid abuse in patients with chronic pain at initial evaluation. A prospective, observational study. Pain Physician 2004; 7:431-437.
10. Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, Fanciullo GJ. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003; 97:1097-1102.
11. Manchikanti L, Cash KA, Damron KS, Manchukonda R, Pampati V, McManus CD. Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables. Pain Physician 2006; 9:215-226.
12. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of self-reported drug use in chronic pain patients. Clin J Pain. 1999;15:184-191.
13. Berndt S, Maier C, Schutz HW. Polymedication and medication compliance in patients with chronic non-malignant pain. Pain. 1993;52:331-339.
14. Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007;22:485-490.
15. Ives TJ, Chelminski PR, Hammett-Stabler CA, et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;4(6):46.
16. West R, Pesce A, West C, et al. Observations of medication compliance by measurement of urinary drug concentrations in a pain management population. J Opioid Manag. 2010;6(4):253-257.
17. Cook RF, Bernstein AD, Arrington TL. Methods for assessing drug use prevalence in the workplace: a comparison of self-report, urinalysis, and hair analysis. Int J Addict. 1995;30:403-426.
18. Owen GT, Burton AW, Schade CM, Passik SD. Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician. 2012;15:ES119-ES133.
19. Owen GT, Chundru S, Dolinak D, Crockett K. Pain Medicine Accidental Drug Overdoses in Travis County during 2011. A Texas Medical Society, Physician Oncology Education Program, and Cancer Prevention and Research Institute of Texas educational program. Available at www.texmed.org/opioidabuse.
Graves T. Owen is medical director, Texas Pain Rehabilitation Institute PA. He has been a pain management physician in private practice since 1995. He is a diplomat of the American Board of Anesthesiology and American Academy of Pain Management, president for the Texas Pain Society and past president of the Austin Pain Society.