The shadow of prescription painkiller abuse now looms more ominously than ever before. As starkly detailed in a December 2016 Morbidity and Mortality Weekly Report, opioids in 2015 accounted for more than two-thirds of all drug overdose deaths in the United States, 15.6% more than the previous year, and drug overdose deaths nearly tripled between 1999 and 2014. Yet opioids remain a mainstay of pain management, upping the stakes for monitoring prescription compliance and detecting abuse.
Government agencies and medical groups recommend clinical laboratory tests to support efforts aimed at curbing abuse. However, many physicians working on the front lines of the opioid crisis may not be fully equipped with knowledge for the task. For example, studies have shown that clinicians misunderstand the very urine immunoassay tests they order for patients. One study found that less than a quarter of physicians correctly answered questions about urine drug tests related to drug metabolism, the effects of passive inhalation of marijuana, and whether morphine or codeine are present in poppy seeds.
While such research indicates the need to improve addiction medicine training among providers managing chronic pain, ever advancing techniques in clinical laboratories redouble the potential for physicians to be unaware of best testing practices. Given this whirl of complexity the National Pain Strategy, National Safety Council, and other initiatives emphasize the need to educate physicians about pain management, and indeed, at least 17 states mandate education for pain medication subscribers. Clinical laboratory professionals have a crucial role in this education process.
At Mayo Clinic in Rochester, Minnesota, for example, physician calls for help interpreting pain management tests rose after the Centers for Disease Control and Prevention in March 2016 issued guidelines recommending urine drug testing before starting patients on opioid therapy and for monitoring them afterward. This guideline and others “are driving the testing, but also leading to more confusion in terms of which type of laboratory tests to use—for example, immunoassays versus definitive methods—which specific tests to include, the frequency, and how to interpret those tests,” said Paul Jannetto, PhD, DABCC, FACB, MT (ASCP), director of Mayo’s clinical and forensic toxicology laboratory.
Jannetto along with his Mayo Clinic colleague, Loralie Langman, PhD, DABCC, served as vice-chair and chair, respectively, of AACC Academy’s forthcoming Laboratory Medicine Practice Guideline (LMPG), Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. Langman is director of Mayo’s toxicology and drug monitoring laboratory.
As not only the diagnostic testing arm for three hospitals and affiliated health networks in Florida, Arizona, and Minnesota but also a major reference lab, Mayo deploys many tools to help providers navigate the nuances of drug testing. Mayo’s online test catalog includes a primer on interpreting drug tests for compliance, along with 5- to 15-minute “hot topic” videos and other online education. For example, one featuring Langman is titled, “Drugs of Abuse Testing: Ordering the Right Test at the Right Time, and What Does It Mean?”
Jannetto, Langman, and their colleagues also make in-person and online presentations. But phone consultations are sometimes still necessary. Altogether, real-time conversations represent almost half of their daily calls. “It’s an important and core component of our job,” said Jannetto.
The personal touch also works particularly well at Vanderbilt University Medical Center in Nashville, Tennessee, according to Jennifer Colby, PhD, DABCC, FACB, director of toxicology and special chemistry. Like Mayo, Vanderbilt offers online resources tied to its testing menu. However, Colby has found that giving presentations “on how tests work and intricacies relevant to physicians’ practices,” sets the stage for ongoing collaboration. “People will continue to reach out, once they know a resource is available,” she added. “They always come to us with questions.”
Vanderbilt also is harnessing technology to facilitate even more lab-physician consultations, due in part to new Tennessee state drug testing requirements. “We have a lot more physicians ordering tests who have less experience interpreting,” Colby explained. To ease the drug testing process for these and other providers, Vanderbilt now makes it possible for physicians to request interpretative services at the time they order a test. As CLN went to press, Colby was still compiling data on the reach of this new approach.
Weill Cornell Medicine in New York City has found success coupling lower key interactions with formal grand rounds addressing topics of importance to specific departments. “We are trying to be more visible to our clinical colleagues by proactively contacting clinicians to discuss issues and needs and just being at case rounds,” explained assistant professor Joshua Hayden, PhD, DABCC. “Being present and able to provide insights helps develop a relationship where they know who you are and feel comfortable approaching you with questions and concerns.”
Time for a New Menu?
Illicit drug use on top of prescribed medications complicates some patients’ clinical pictures. Worrisome and deadly street formulations of fentanyl and its analog carfentanil have landed in areas already beset with prescription opioid abuse. Plus the designer drug landscape never stops changing. For these reasons, clinical labs and their physician clients need to work together to stay abreast of drug testing needs in their local communities. Indeed, the feedback loop between laboratorians and providers holds sway in determining how and when test menus change, who directs the changes, and testing method choices and algorithms.
Clinical Laboratories of Hawaii, for example, maintains practice-specific menus, according to Clifford Wong, PhD, ABFT, director of toxicology. “The doctors have their own programs for pain management, and they let us know what their needs are, and we adapt our tests,” he explained. “We coordinate with them and customize for each doctor’s needs. But we’ll tell them there’s a flaw in their panel if they have a misconception about what to expect. We inform physicians about the limitations of immunoassay screens, and the necessity for mass spectrometry confirmation for positive tests in specific scenarios.”
Colby’s experience underscores the necessity of closely monitoring local prescription and illicit drug use trends, in collaboration with providers. At Vanderbilt, prescription opioid abuse prevails, but in her prior position at a safety net hospital in San Francisco, she saw a high prevalence of methamphetamine and heroin use. Recently, however, heroin use has been rising in Tennessee in parallel with the state’s ramped up oversight of opioid prescribing.
“Generally, as a community we’ve done a pretty good job of offering these tests and trying to follow drug trends, but it’s also very hard because they change quickly and they’re very region-specific, so we struggle a little to stay on top of things,” said Colby. She added that with limited resources and personnel, Vanderbilt’s immunoassay-based screening menu is fairly set; she makes one or two adjustments per year.
Langman and Jannetto cautioned not to overlook testing for alternative—herbal, naturopathic, traditional Chinese, or ayurvedic—medications in some patients. “Our pain profile is definitely geared toward Western medicine, so we are looking at the typical pharmaceuticals,” said Langman. “However, alternative medications are known to have active components, but they’re not necessarily tested for.” Labs typically do not receive or have access to comprehensive lists of patient medications but should emphasize in their education outreach to physicians the need to obtain this information, Jannetto added.
The AACC Academy LMPG—in draft as the committee addresses comments received from AACC members—contemplates three tiers of testing, starting with medications most pain management practices should test for, Langman explained. Subsequent testing would vary based on individual patient needs and their risk of abuse for drugs.
In addition to educating and consulting closely with physicians and tweaking testing menus, labs in their quest to provide optimal pain management support might also take a close look at their testing methods. Many have already or are considering implementing mass spectrometry for both screening and confirmatory testing, but Langman suggested that mass spectrometry is not an absolute must. “Our recommendation, if at all possible, is to do definitive screening as the first line approach. That frequently but not always is a mass-spec based approach,” she said. “There is still a role and place for immunoassay-based screening when mass spec isn’t necessarily available.”
Brittany Moya del Pino is a freelance writer in Kailua, Hawaii.+Email: [email protected]