Does the perceived accuracy of urine drug testing impact clinical decision-making?

Background: Urine drug testing techniques have different rates of false-positive and false-negative test results. However, clinicians may have highly varying perceptions of test accuracy and may compensate for perceived inaccuracy by incorporating other factors into their interpretation of observed test results. Thus, there is the potential for adverse consequences from decisions based on inaccurate test results or interpretation. Methods: We surveyed 466 members of the American Society of Addiction Medicine to examine clinicians' perceptions of the accuracy of 2 types of urine drug tests, immunoassay (IA) and liquid chromatography-tandem mass spectrometry (LC-MS/MS), and the extent to which behavioral and demographic factors influence the interpretation of test results. Participants read 4 brief vignettes describing positive and negative test results in hypothetical patients who differed along several dimensions (gender, age, race/ethnicity, comorbid mental disorder, court-ordered versus voluntary status, treatment compliance). Outcome variables include likelihood of renewed drug use, likelihood of test error, whether to request additional testing, and whether to report the violation to a probation officer. Results: The strongest predictor of study outcomes was treatment compliance (consistent versus inconsistent attendance), as this was the only independent variable to generate effect sizes of medium strength. Significant effect sizes were also found for type of test used (IA versus LC-MS/MS), legal status (court-mandated versus voluntary), presence of a comorbid mental disorder, treatment history, and race, although effect sizes for these variables were small and less consistently observed. Conclusions: These results highlight the potential for error in clinician judgments about urine drug testing. Not only were participants likely to underestimate the accuracy of "confirmatory" LC-MS/MS testing, but vignettes suggested that a number of historical and demographic factors may influence interpretation of test results.

Sleep problems in breast cancer survivors 1-10 years posttreatment.

ABSTRACTObjective:Sleep can affect quality of life (QoL) during cancer survivorship, and symptoms related to poor sleep can be exacerbated. We examined the prevalence, severity, and nature of subjective sleep complaints in women surviving stage I-III breast cancer who were 1-10 years posttreatment. We also examined the demographic, medical, physical, and psychosocial correlates of poor sleep in these women in order to identify the subgroups that may be most in need of intervention. METHOD: A total of 200 patients at a comprehensive cancer center who were 1-10 years posttreatment for primary stage I-III breast cancer with no evidence of disease at the time of enrollment completed a battery of questionnaires on demographics, sleep, physical symptoms, mood, cancer-specific fears, and QoL. RESULTS: The women had a mean age of 57 years (SD = 10.0), with a mean of 63.3 months (SD = 28.8) of post-cancer treatment. Some 38% of these patients were identified as having poor-quality sleep. Women with poor sleep took longer to fall asleep, had more awakenings, and acquired 2 hours less sleep per night than those with good sleep. They also had a lower QoL, greater severity of pain, more concerns about health and recurrence, and increased vasomotor symptoms (p < 0.05). Daytime sleepiness and depression were found to be not significantly correlated with sleep quality. SIGNIFICANCE OF RESULTS: Many breast cancer survivors had severe subjective insomnia, and several breast cancer survivor subgroups were identified as having members who might be most in need of sleep-improvement interventions. Addressing physical symptoms (e.g., vasomotor symptoms and pain) and providing education about the behavioral, social, environmental, and medical factors that affect sleep could result in substantial improvement in the life course of breast cancer survivors.

An Online Survey of Patients' Experiences Since the Rescheduling of Hydrocodone: The First 100 Days.

OBJECTIVE: To conduct an Internet patient survey through the National Fibromyalgia & Chronic Pain Association on reactions to the first 100 days following the rescheduling of hydrocodone. METHODS: Face-valid survey questions were created with expert consensus along with repurposed questions used on previous NFMCPA surveys covering domains such as demographics and symptoms. The questionnaire was designed to be administered over the Internet. RESULTS: 6,420 responders met screening criteria and completed the survey. Most (5,181, or 82.5%) had been prescribed hydrocodone for more than 1 year. 2,296, (39.0%) reported no changes in access to hydrocodone, while the majority experienced some barriers. Of those who could no longer get hydrocodone, 1,067 (18.1%) borrowed pain medications, 1,007 (17.1%) turned to marijuana, 773 (13.1%) used alcohol, and 135 (2.3%) used illicit drugs. Most respondents had to visit their healthcare providers more often (N = 3,699, 64.2%) and 1,735 (30.3%) reported some type of issue interacting with their pharmacy. Most felt that the rescheduling was neither a fair nor appropriate solution to the abuse of hydrocodone (N = 4,938, 88.3%). For those still working, 801 (46.2%) reported that they had missed work because of the stricter regulations. 1,462 (27.2%) reported having thoughts of suicide since the rescheduling. SIGNIFICANCE: The unintended consequences for people with chronic pain that have been caused by the rescheduling effort to impede hydrocodone abuse are negatively impacting thousands. These consequences include suffering from being placed on less effective drugs, increased cost, inconvenience, and negative influence on physician-patient and pharmacist-patient relationships.

The complexity model: a novel approach to improve chronic pain care.

OBJECTIVE: More than 25% of the US population experiences chronic pain; yet few physicians specialize in the field of pain medicine. This article will review a theoretical model of care that stratifies treatment and patients by level and type of complexity and promotes communication between specialist and primary care providers. DISCUSSION: The undertreatment of pain was recently brought to national attention to encourage both clinicians and patients to advocate for improved pain care. The specialty of pain medicine and models of care, challenges of managing pain in a primary care setting, and the reliance on an opioid-focused approach are reviewed. An evolved model of pain care based on the complexity of pain and emphasizing a dynamic collaboration between the primary care provider and the pain specialist is discussed. CONCLUSIONS: From the perspective of the busy clinician, the treatment of chronic pain can be overwhelming. The scarcity of trained pain practitioners and the burgeoning number of patients with chronic pain necessitate a new approach that values the complex nature of chronic pain and offers a practical blueprint to meet these challenges.

Frequency, characteristics, and correlates of pain in a pilot study of colorectal cancer survivors 1-10 years post-treatment.

OBJECTIVE: The long-term effects of disease and treatment in colorectal cancer (CRC) survivors are poorly understood. This study examined the prevalence and characteristics of pain in a sample of CRC survivors up to 10 years post-treatment. DESIGN: One hundred cancer-free CRC survivors were randomly chosen from an institutional database and completed a telephone survey using the Brief Pain Inventory, Neuropathic Pain Questionnaire-Short Form, Quality of Life Cancer Survivor Summary, Brief Zung Self-Rating Depression Scale, Zung Self-Rating Anxiety Scale, and Fear of Recurrence Questionnaire. RESULTS: Participants were primarily Caucasian (90%) married (69%) males (53.5%) with a mean age of 64.7 years. Chronic pain was reported in 23% of CRC survivors, with a mean moderate intensity rating (mean = 6.05, standard deviation = 2.66) on a 0-10 rating scale. Over one-third (39%) of those with pain attributed it to their cancer or treatment. Chi-square and t-test analyses showed that survivors with pain were more likely to be female, have lower income, be more depressed and more anxious, and show a higher endorsement of suicidal ideation than CRC survivors without chronic pain. On average, pain moderately interfered with daily activity. CONCLUSIONS: Chronic pain is likely a burdensome problem for a small but not inconsequential minority of CRC survivors requiring a biopsychosocial treatment approach to improve recognition and treatment. Open dialogue between clinicians and survivors about physical and emotional symptoms in long-term follow-up is highly recommended.

Development and implementation of a palliative care consultation tool.

OBJECTIVE: Palliative care services are becoming more commonplace in hospitals and have the potential to reduce hospital costs through length of stay reduction and remediation of symptoms. However, there has been little systematic attempt to identify when a palliative care consultation should be triggered in a hospital, and there is some evidence that these services are under-utilized and not fully understood. METHOD: In an initial attempt to address when a consultation might be appropriate, we attempted to pilot test a novel palliative care screening tool to help guide clinician judgment in this regard. A one-page, face-valid instrument was developed using expert opinion. RESULTS: The sample comprised 33 men (44.6%) and 41 women (55.4%) with an average age of 63.4 years (SD = 13.8) and an average length of stay of 22.7 days (SD = 10.1). The most significant symptom was pain, indicated as moderate-to-severe in 23 patients (31%). This was followed by fatigue (n = 10, 13.5%) and nausea (n = 6, 8.1%). At unit entry, 20 patients (33%) had moderate or severe pain. Upon discharge, this number had been reduced to 12/60 (20%). Chi-Square analysis showed a significant decrease in pain rankings overall (χ2 = 36.3, p < 0.0001). The average total tool score was 7.5 (SD = 3.1). Using an initial threshold of 12 to trigger a palliative care referral, 64 patients (86.5%) would not have received a referral and 10 (13.5%) would have. Of these 10 patients, 2 (20%) did not receive a palliative care consultation while they were hospitalized. SIGNIFICANCE OF RESULTS: The tool we developed increased consultations over the time period in which it was used, compared with the same time period 1 year prior. Although the threshold developed for triggering referrals seemed artificially high, the implementation of the screening tool did increase referrals.

Assessing self-efficacy for coping with cancer: development and psychometric analysis of the brief version of the Cancer Behavior Inventory (CBI-B).

OBJECTIVE: The Cancer Behavior Inventory-Brief Version (CBI-B), a 12-item measure of self-efficacy for coping with cancer derived from the longer 33-item version, was subjected to psychometric analysis. METHOD: Participants consisted of three samples: 735 cancer patients from a multicenter CCOP study, 199 from central Indiana, and 370 from a national sample. Samples were mixed with respect to initial cancer diagnosis. Participants completed the CBI-B and measures of quality of life, optimism, life satisfaction, depression, and sickness impact. RESULTS: Exploratory Factor Analysis with oblique rotation yielded four factors in the first sample: (1) Maintaining Independence and Positive Attitude; (2) Participating in Medical Care; (3) Coping and Stress Management; and (4) Managing Affect, which were confirmed in subsequent samples. Cronbach α coefficient for the 12-item CBI-B ranged from 0.84 to 0.88. Validity of the CBI-B was demonstrated by positive correlations with measures of quality of life and optimism, and negative correlations with measures of depression and sickness impact. CONCLUSION: The CBI-B is a valid brief measure of self-efficacy for coping that could be easily integrated into clinical oncology research and practice, and also used in screening patients.

Multimodal approaches to optimize outcomes of chronic opioid therapy in the management of chronic pain.

OBJECTIVE: To review clinical strategies for long-term opioid management as well as strategies to assess and monitor patients with moderate to severe chronic pain who may be at risk for aberrant drug-related behaviors. DESIGN: A symposium was held to disseminate a review of opioid use strategies, including use of the Universal Precautions in Pain Medicine as well as the Federation of State Medical Boards Model Policy for Prescribing Controlled Substances (FSMB model policy). These include continual reassessment of pain and risk, treatment agreements, compliance monitoring, urine drug screening, documentation, compliance with the law, and patient education. Additionally, the use of multimodal strategies to treat patients, with techniques such as cognitive-behavioral therapy, is discussed as an essential part of a comprehensive pain management plan. SETTING: The review summarizes a continuing medical education (CME)-accredited symposium conducted at the American Pain Society Annual Meeting in Baltimore, Maryland, in May 2010. RESULTS: Recommendations for the management and monitoring of long-term opioid therapy for patients with chronic noncancer pain are rooted in evidence-based clinical guidelines, which also provide guidance for the identification of aberrant behaviors or overt addiction. CONCLUSIONS: Vigilance and frequent interactions may sometimes be inadequate to prevent problematic behaviors; therefore, pharmacologic strategies designed to deter abusive behaviors are also discussed.

Issues and critiques of the forthcoming risk evaluation and mitigation strategy (REMS) for opioids in pain management.

OBJECTIVE: To examine the history and suitability of the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) for reducing the safety risks associated with the use of opioid medications, including the risks of abuse and overdose. This article will highlight recent attempts by the FDA to introduce a class wide REMS for new and existing Schedule II long-acting opioid drugs. A critique of these current REMS efforts and recommendations for the future will also be provided. DESIGN: A literature review and commentary design are utilized to highlight issues surrounding REMS efforts and to explore possible future directions. Expert opinion is offered to potentially guide future efforts in this arena. CONCLUSIONS: The stated goal of the FDA's proposed class wide opioid REMS program is to decrease abuse, misuse, addiction and overdose deaths from opioid medications. While the REMS program may have theoretical capabilities for evaluating and addressing problematic drug use among prescribed patients, it is unlikely to reduce the bulk of prescription drug abuse that occurs with non-patients. Our recommendations provide some ideas on how the REMS program can be improved to achieve the goals set for it by Congress and the FDA.

Special issues and concerns in the evaluation of older adults who have pain.

Older patients who have pain present unique challenges for clinicians. On the one hand, care must be taken to treat the pain aggressively while avoiding hampering the patient with excessive side effects, such as drowsiness, nausea and vomiting, and constipation. On the other hand, the clinician must be aware of the growing problem of prescription drug abuse and assess whether or not the patient or his or her family is at risk. Indeed, the concern for assessment is not solely centered on the patient but also extends to the family and extended support network, which may or may not have the patient's best interests at heart when it comes to pain medications. Supposing that addiction and abuse are solely the purview of the young is no longer acceptable, and we have the burden of assessing for problematic behavior while also trying to convince some patients that they would benefit from pain medicine.

The interface between pain and drug abuse and the evolution of strategies to optimize pain management while minimizing drug abuse.

Pain management is facing continued undertreatment of pain despite a growing problem with prescription opioid abuse. This has created a tension among prescribers and feelings of helplessness with regards to what constitutes appropriate practice. This article provides a review of pain management efforts and focuses on two key areas of potential interest. First, the emergence of prescreening tools for identifying appropriate candidates for opioid therapy are introduced and discussed, including the Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Pain Assessment and Documentation Tool (PADT). In addition to these screening efforts, a novel concept of "in and out of the box" prescribing is presented, focusing on five areas of concern for judging whether one's prescribing patterns are matching peer prescribing patterns. While more work needs to be done, the discussion of these areas should offer some questions for self analysis by physicians regarding their prescribing patterns. Overall, the authors must embrace the concept of rational pain management and assess patients for risk both before writing the first opioid prescription for them and thereafter. In addition, we must remember that good pain management should lead to some decreases in pain perception for the patient combined with a corresponding increase in ability to function. By reviewing these tools and proposed novel guidelines for in/out of the box prescribing and adopting them into practice as appropriate, the physician will take a significant step in providing effective pain management while minimizing risk of opioid misuse.

Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress.

Screening for distress in cancer patients is recommended by the National Comprehensive Cancer Network, and a Distress Thermometer has previously been developed and empirically validated for this purpose. The present study sought to determine the rates and predictors of distress in a sample of patients being seen in a multidisciplinary lung cancer clinic. Consecutive patients (N=333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List, and two questions about interest in receiving help for symptoms. Over half (61.6%) of patients reported distress at a clinically significant level, and 22.5% of patients indicated interest in receiving help with their distress and/or symptoms. Problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical functioning, and cognitive functioning were associated with higher reports of distress. Specific symptoms of depression, anxiety, pain and fatigue were most predictive of distress. Younger age was also associated with higher levels of distress. Distress was not associated with other clinical variables, including stage of illness or medical treatment approach. Similar results were obtained when individuals who had not yet received a definitive diagnosis of lung cancer (n=134) were excluded from analyses; however, family problems and anxiety were no longer predictive of distress. Screening for distress in a multidisciplinary lung cancer clinic is feasible and a significant number of patients can be expected to meet clinical criteria for distress. Results also highlight younger age and specific physical and psychosocial symptoms as predictive of clinically significant distress. Identification of the presence and predictors of distress are the first steps toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients' distress.

Documentation and potential tools in long-term opioid therapy for pain.

The field of pain medicine is experiencing increased pressure from regulatory agencies and other sources regarding the continuation, or even initial use, of opioids in pain patients. Therefore, it is essential that pain clinicians provide rationale for engaging in this modality of treatment and provide ample documentation in this regard. Thus, assessment and documentation are cornerstones for both protecting your practice and obtaining optimal patient outcomes while on opioid therapy. Several potential tools and documentation strategies re discussed that will aid clinicians in providing evidence for the continuation of this type of treatment for their patients.

Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse.

OBJECTIVES: This study evaluated the prevalence and correlates of aberrant drug-taking behaviors in two populations: patients with HIV-related pain and a history of substance abuse (n = 73) and patients with cancer pain and no history of substance abuse (n = 100). METHODS: All patients completed a Drug-Taking Behaviors Interview, the Brief Symptom Inventory (BSI), Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale (MSAS), and the Marlowe Crowne Social Desirability Scale (MCSDS). The Pain Management Index was calculated to assess the adequacy of opioid prescribing. RESULTS: The cancer sample comprised 38 men and 62 women, and the AIDS sample comprised 63 men and 10 women. Patients with AIDS-related pain had higher global distress on the MSAS (F1, 170 = 20.05, P < 0.001), greater pain-related interference in their daily functioning on the BPI (F1, 161 = 22.87, P < 0.001), and a lower percentage of relief from their current medications (F1, 156 = 76.14, P < 0.001). AIDS patients also reported more than twice as many examples of aberrant drug-related behaviors per patient (mean = 6.14, SD = 4.60) as the cancer patients (mean = 1.42, SD = 1.91). CONCLUSION: These data suggest that AIDS patients with histories of substance abuse receiving opioid therapy are more symptomatic, have more distress, experience more interference from residual pain, and engage in more problematic drug-related behaviors than patients with no history of drug abuse receiving opioids for cancer pain. Treatment of substance abusers with pain requires skills that complement best practices in opioid prescribing. Better approaches to the long-term treatment of these populations are needed.

Psychiatric and pain characteristics of prescription drug abusers entering drug rehabilitation.

There has been intense interest in the problem of prescription drug abuse on the parts of health professionals, law enforcement, the media, and the general public. Clinicians not only need to know how to assess risk but also what drugs are being diverted most in their region. We conducted a prospective survey of prescription drug abusers entering a treatment facility in central Kentucky. Participants (n = 109) were enrolled and completed a structured clinical interview and prescription drug abuse survey. The prescription drug abusers assessed in the study had a mean age of 30.95 years (SD = 10.21), were comprised of 75 men (69%) and 34 women (31%), and were mostly Caucasian (98%). The majority (84%) stated that they had legitimately been given a prescription for opioids for pain at some point from a physician and 61% reported chronic pain concerns. The most commonly abused drugs were hydrocodone-containing formulations (78%) and oxycodone-containing products (69%), while products containing methadone (23%) or fentanyl (7%) were abused much less frequently. Most respondents (91%) stated that they had purchased prescription opioids from a street dealer at least once and the majority (80%) had altered the delivery system of the prescription drug by chewing, snorting, or using i.v. administration. Implications for pain management are discussed, focusing on the need for clinicians treating chronic pain to more thoroughly assess patients for their risk of abuse and addiction before starting an opioid regimen.

Definitive LC-MS/MS Drug Monitoring Impacts Substance-use Treatment Planning and Patient Outcomes: A Brief Report.

Clinical drug monitoring has an increasingly important role in the treatment of substance use disorders. Through semistructured interviews, we asked substance-use counselors about the clinical impact of drug tests on patients' treatment planning and outcomes. This study was conducted around the time of a facility-wide switch to a laboratory utilizing definitive liquid chromatography with tandem mass spectrometry from a laboratory that had utilized the less-sensitive, presumptive immunoassay-based drug-testing methodology. Twelve counselors volunteered to be interviewed, and each counselor chose 2 patients to discuss. Counselors reported that the facility-wide switch to definitive drug testing revealed some patients with newly identified relapses and substance use. They also reported that, as a result of the new information provided by definitive liquid chromatography with tandem mass spectrometry monitoring, 75% of the patients they discussed had a change made to their treatment plan, 79% were provided enhanced education, and 63% had an increase in their treatment intensity. Counselors also reported that 58% of these patients reduced their illicit drug and nonmedical prescription medication use as a result of treatment changes associated with the newly implemented definitive testing. Improvements in therapeutic relationships and honesty were also reported. These preliminary data are consistent with previous data and guidelines, suggesting that the results of definitive drug monitoring inform clinical decision-making and can help clinicians enhance treatment outcomes.

Counselors' Clinical Use of Definitive Drug Testing Results in Their Work with Substance-Use Clients: a Qualitative Study.

We conducted a psychotherapeutic examination of the use of definitive drug testing (liquid chromatography with tandem mass spectrometry) in the treatment of substance use disorders (SUD). Employing a generic qualitative method (Caelli et al. in International Journal of Qualitative Methods, 2(2), 2003; Merriam, 2009) we asked SUD counselors to provide narratives about cases where drug testing had revealed new or unexpected information about clients' drug-taking behaviors. Semi-structured interviews with 12 SUD counselors were conducted by phone and analyzed for themes derived from the literature. These counselors reported many new positive drug tests in clients previously believed to be adherent with treatment. Key themes assessed in counselors' narratives included initial client denial that was often followed by later acknowledgement of relapse and increased motivation, at times presenting new opportunities for clients to engage in treatment and enhance the therapeutic alliance. These results suggest that definitive drug testing can be used in a non-stigmatizing and therapeutic manner.

FDA/DEA/PDMP/UDT: alphabet soup or sensible and integrated risk management?

OBJECTIVE: Both prescription drug monitoring programs (PDMP) and urine drug testing (UDT) are recommended as parts of an ongoing risk management approach for controlled substance prescribing. The authors provide an editorial and commentary to discuss the unique contributions of each to promote better clinical decision making for prescribers. DESIGN: A commentary is employed along with brief discussion comparing four states with an active PDMP in place to three states without an active PDMP as it relates back to findings on UDT in those states from a laboratory conducting liquid chromatography tandem mass spectrometry. CONCLUSIONS: The commentary focuses on the place of both tools (UDT and PDMP) in risk management efforts. The argument is made that relying on a PDMP alone would lead to clinical decisions that may miss a great deal of problematic or aberrant behaviors.

A primer on definitive gas and liquid chromatography drug testing: What clinicians need to know.

OBJECTIVE: To describe the differences between mass spectrometry technologies and compare and contrast them with immunoassay techniques of urine drug testing (UDT). Highlight the potential importance of the differences among these technologies for clinicians so as to allow them make decisions in their use in patient care. METHODS: Review of mass spectrometry techniques, including gas chromatography, liquid chromatography, and time-of-flight techniques. RESULTS: The potential clinical implications of these technologies stemming from their scope and accuracy are presented. SIGNIFICANCE: UDT is an important clinical tool, though there are differences in technology and testing processes with important implications for clinical decision making. It is crucial, therefore, that clinicians have an understanding of the technologies behind the tests they order, so that their interpretation and use of results are based on an understanding of the strengths and weaknesses of the technologies used.

Specimen validity testing in urine drug monitoring of medications and illicit drugs: clinical implications.

OBJECTIVE: To discuss the importance of specimen validity testing (SVT) in urine drug testing (UDT) and the clinical role it plays in identifying efforts to subvert the UDT process. METHODS: A discussion of the clinical impact of SVT is presented. RESULTS: A discussion of pH, specific gravity, creatinine, and oxidation for monitoring the adulteration of UDT samples is presented along with the clinical significance of such tests. SIGNIFICANCE: SVT has a significant place in healthcare efforts to measure patient adherence, behavior, and honesty in communication with clinicians. SVT is typically ordered by treating clinicians who use the results to make therapeutic decisions regarding specific medical problems of their patient, including those related to medication and illicit drug use. In the absence of SVT, a healthcare provider may fail to identify a patient's adulteration of their urine sample in an attempt at deceiving the provider. Moreover, the presence of some underlying medical conditions may obfuscate the UDT results.