Testing the Pain Management (PM) Patient

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The page below is a sample from the LabCE course The Toxicology Laboratory's Role in Pain Management: Testing for Opiates. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

Learn more about The Toxicology Laboratory's Role in Pain Management: Testing for Opiates (online CE course)
Testing the Pain Management (PM) Patient

The frequency of urine testing in PM depends on the agreement made between the patient and clinician (the opiate therapy plan or contract), as well as the nature of the patient. Patients who have a history of drug abuse or alcohol abuse will require more frequent monitoring than those at lower risk for addictive behaviors.
Many patients will present to clinicians complaining of pain and will not be content to leave the clinician's office without a prescription for a narcotic. Patients who "doctor shop," trying to get prescriptions for pain medication, are relatively common. Some characteristics of patients who exhibit drug-seeking behavior are listed in the accompanying table. Prescribing narcotics to patients who do not have a genuine clinical need for them can cause clinicians to lose their license to prescribe medications or practice medicine. The stakes are high for patients and clinicians when it comes to opiate use. Thus, asking patients to undergo testing to monitor appropriate prescription drug use should not be seen as punitive but rather expected, given the high abuse rates for prescription drugs and the potential risk to the professional reputation of the ordering clinician.
Clinicians will often test the urine of patients who are prescribed opiates every six months. In patients with abuse histories or patients who have had previous abnormal urine screens, clinicians may elect to have patients tested every time they refill their prescription.
Some health care organizations also allow clinicians to order a pill count. A pill count is an order that instructs the patient to go to the pharmacy and have the pharmacist count how many opiate pills are remaining in the prescription container. The pharmacist can easily tell if the pills are indeed the prescribed medication and whether or not there are too few remaining, given the elapsed time period. Pill counts are another way to manage patients with suspicious behaviors.
Ordering urine DOA screens on PM patients is very useful to verify whether the patient is compliant with the PM plan. The clinician expects to see the presence of the prescribed drug and will check to make sure that other abused drugs are not present.
One problem with urine screening in PM patients is that the collections are usually not supervised. Usually, patients are asked to submit samples they collect themselves. This unsupervised collection means that patients could be submitting samples that are not theirs, samples that have been chemically altered, or samples that have been diluted. Supervised collections are more common in addiction medicine clinics or in laboratories that do employee screening. However, the line between PM and addiction medicine can quickly blur and some laboratories may receive specimens from supervised as well as unsupervised collections.
Urine DOA screens are only useful if the clinician and the laboratory professionals know how to interpret the findings.