The Hidden Cost of the Opioid Epidemic in the United States: Drug Screening in Insurance Claims.

BACKGROUND: The opioid crisis has had a substantial financial impact on the health care system in the United States. This study evaluates how health plans have been affected financially and shows how a laboratory benefit management (LBM) program can be used to address related drug testing in an outpatient setting. METHODS: Monthly claims data from private health plans were collected from June 1, 2016 to February 29, 2020. The total number of claims (units) for definitive and presumptive drug testing were calculated and the number of paid claims recorded. Claims distribution by laboratory type and medical code billed, the paid rate and compound annual growth rate, and the test distribution and paid rate of rendering providers who had submitted a minimum of 1000 claims were determined. RESULTS: In total, 2,004,230 drug testing claims were submitted. After the LBM program was implemented, the percentage of paid claims for definitive drug testing (Healthcare Common Procedure Coding System code G0483) decreased and the paid rate for the low-cost tests (HCPCS code G0480) in physician office and independent laboratory settings increased. The compound annual growth rate for G0483 claims submitted indicated a 70.5% and 31.9% decrease in payments to physician offices and independent laboratories, respectively, for the period ending February 2020. CONCLUSIONS: An LBM program can positively address policy enforcement while reducing unnecessarily complex tests and limiting potential fraud, waste, and abuse by directing testing toward laboratories amenable to cost-efficient contractual savings. Moreover, for definitive drug testing, the enforcement of the use of Healthcare Common Procedure Coding System codes and a move toward more cost-efficient tests (G0480), when clinically applicable, supported by clinical practice guidelines, or evidence-based medicine, is an approach to providing medical benefits while maintaining health costs.

An Argument Against Drug Testing Welfare Recipients.

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous-aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

Clinical and financial implications of emergency department visits for synthetic marijuana.

BACKGROUND: Many users believe that synthetic cannabinoids offer a safe and legal means of getting high. However, spikes in emergency department visits have been associated with use of synthetic cannabinoids. The purpose of the current study was to document emergency department visits from three large hospitals in one metropolitan area over a two month period. METHOD: This was a retrospective chart review examining 218 patients presenting to three inner city emergency departments between March and April 2014. Data collected included demographic information, information regarding ED diagnosis and treatment, signs and symptoms, ancillary testing, ED disposition, and cost of the medical treatment. RESULTS: The majority of patients (75.7%) were discharged after ED workup, but 12.4% were admitted for medical treatment and 11.5% were admitted for psychiatric treatment. Ten patients (4.6%) were admitted to the ICU. Symptoms experienced most frequently include: hypertension, tachycardia, agitation, drowsiness, nausea, and confusion. Cluster analysis revealed four symptom clusters of individuals presenting after using synthetic cannabinoids: 1) confusion, hostility, agitation, 2) nausea, vomiting, abdominal pain, 3) drowsiness, and 4) the absence of these symptoms. CONCLUSION: This study has three important findings. First, significant ED resources are being used to treat individuals presenting due to effects of synthetic cannabis. Second, synthetic cannabis is not a benign substance. Third, while the hostile and agitated user is generally presented in the media, this study finds significant heterogeneity in presentation. Further research is needed to fully understand the implications of synthetic cannabinoid use.

Development of a rapid column-switching LC-MS/MS method for the quantification of THCCOOH and THCCOOH-glucuronide in whole blood for assessing cannabis consumption frequency.

The concentration of 11-nor-9-carboxy-Δ(9)-tetrahydrocannabinol (THCCOOH) in whole blood is used as a parameter for assessing the consumption behavior of cannabis consumers. The blood level of THCCOOH-glucuronide might provide additional information about the frequency of cannabis use. To verify this assumption, a column-switching liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the rapid and direct quantification of free and glucuronidated THCCOOH in human whole blood was newly developed. The method comprised protein precipitation, followed by injection of the processed sample onto a trapping column and subsequent gradient elution to an analytical column for separation and detection. The total LC run time was 4.5 min. Detection of the analytes was accomplished by electrospray ionization in positive ion mode and selected reaction monitoring using a triple-stage quadrupole mass spectrometer. The method was fully validated by evaluating the following parameters: linearity, lower limit of quantification, accuracy and imprecision, selectivity, extraction efficiency, matrix effect, carry-over, dilution integrity, analyte stability, and re-injection reproducibility. All acceptance criteria were analyzed and the predefined criteria met. Linearity ranged from 5.0 to 500 µg/L for both analytes. The method was successfully applied to whole blood samples from a large collective of cannabis consumers, demonstrating its applicability in the forensic field.

Drug Testing US Student-Athletes for Performance-Enhancing Substance Misuse: A Flawed Process.

The author argues that drug testing of U.S. high school students for performance-enhancing substance misuse is invasive, expensive, and the low number of positive test results do not justify the costs, especially in financially strapped school districts where this money would be better spent on injury prevention for athletes and the education of all students.

Inefficiency of the anti-doping system: cost reduction proposals.

The anti-doping system, under the guidance of WADA, costs at least $228 million per year, mostly to cover the cost of performing about 270,000 doping tests. However, "testing has not proven to be particularly effective in detecting dopers/cheats" (WADA). It is suggested, competitions of doping-endangered disciplines be redesigned. Sports with numerous doping cases should be temporarily excluded from the Olympic program and not be televised. Pecuniary fines should be higher and collection guaranteed by a deferred compensation model. Sports with multiple doping offenses should bear most of the anti-doping costs. Finally, appropriate tenders should guarantee fees of anti-doping laboratories develop more competitively.

Simultaneous analysis of synthetic cannabinoids in the materials seized during drug trafficking using GC-MS.

A rapid and simple gas chromatography-mass spectrometry (GC-MS) method was developed and validated to identify and quantify synthetic cannabinoids in the materials seized during drug trafficking. Accuracy and reproducibility of the method were improved by using deuterated JWH-018 and JWH-073 as internal standards. Validation results of the GC-MS method showed that it was suitable for simultaneous qualitative and quantitative analyses of synthetic cannabinoids, and we analyzed synthetic cannabinoids in seized materials using the validated GC-MS method. As a result of the analysis, ten species of synthetic cannabinoids were identified in dried leaves (n = 40), bulk powders (n = 6), and tablets (n = 14) seized in Korea during 2009-2012, as a single ingredient or as a mixture with other active co-ingredients. JWH-018 and JWH-073 were the most frequently identified compounds in the seized materials. Synthetic cannabinoids in the dried leaves showed broad concentration ranges, which may cause unexpected toxicity to abusers. The bulk powders were considered as raw materials used to prepare legal highs, and they contained single ingredient of JWH-073, JWH-019, or JWH-250 with the purity over 70 %. In contrast, JWH-018 and JWH-073 contents in the tablets were 7.1-13.8 and 3.0-10.2 mg/g, respectively. Relatively low contents in the tablets suggest that the synthetic cannabinoids may have been added to the tablets as supplements to other active co-ingredients.

Rapid and simultaneous determination of multiple classes of abused drugs and metabolites in human urine by a robust LC-MS/MS method - application to urine drug testing in pain clinics.

A simple LC-MS/MS method was developed and validated for quantitatively analyzing six classes of 26 abused drugs and metabolites in human urine: (1) illicit drugs; (2) opiates; (3) synthetic opioids; (4) sedative; (5) stimulants; and (6) γ-aminobutyric acid analogs. All urine samples were diluted with a mixture of isotope-labeled internal standards, hydrolyzed with ß-glucuronidase and directly injected in a gradient chromatographic run. The mobile phase was composed of 0.1% formic acid in water and 0.1% of formic acid in methanol. A 4.9 min run time using the multiplexing driver and ultra-biphenyl column (50 × 2.1 mm, 5 µm, RESTEK) allowed all drugs to have sufficient resolution in a short elute time. The overlapping liquid chromatography runs and scheduled multiple reaction monitoring acquisition method resulted in a higher overall throughput for the system. The result was linear over the studied range (2-16,000 ng/mL) for all compounds with correlation coefficients r(2) ≥ 0.995. The intra-day and inter-day precisions and accuracies were within 15% and recovery was between 83 and 115% for all analytes. Freeze-thaw stability for three cycles and long-term stability (57 days, -20°C) were established for all analytes. The cross-validation between College of American Pathologists and in-house was validated (0.06% ≤ bias ≤ 12.3%). The applicability of the method was examined by analyzing urine samples from chronic pain patients (n = 610).

The cost of providing methadone maintenance treatment in Ontario, Canada.

OBJECTIVES: To estimate the cost of providing methadone maintenance treatment in Ontario, Canada, from the perspective of the public payer. METHODS: We analyzed a database of all patient clinic visits, laboratory tests for urine toxicology screening, and methadone scripts from a group of methadone clinics in Ontario. The database consisted of patient visits and visit information from 1 January 2003 to 31 December 2009. We estimated the cost of providing methadone maintenance treatment as the sum of physician costs, laboratory costs for urine samples (toxicology screens), methadone costs, and pharmacy costs. Pharmacy costs include dispensing fees and markups. All costs are expressed in 2010 Canadian dollars. RESULTS: The database consisted of 9479 unique patients. The average age on the date of the first recorded visit was 34.3, and among the patients 62.3% were male. There were 6,425,937 patient days of treatment and the total cost of all treatment-related services was approximately $99,491,000. The total cost was comprised of physician billing (9.8%), pharmacy costs (39.8%), methadone (3.8%), and performing urine toxicology screens (46.7%). The average cost per day for treatment was $15.48, corresponding to $5651per year if patients were to remain in treatment continuously. CONCLUSIONS: The cost of providing methadone maintenance treatment in Ontario is comparable to estimates from the United States and Australia. SCIENTIFIC SIGNIFICANCE: This information is important to policy makers for planning and budgeting purposes and as part of a full cost-benefit or cost-effectiveness analysis of methadone treatment.

[Reimbursement of opiate substitution drugs to militaries in 2007]. / Remboursement des médicaments de substitution aux opiacés chez les militaires en 2007.

INTRODUCTION: The use of psychoactive drugs by militaries is not compatible with the analytical skills and self-control required by their jobs. Military physicians take this problem into consideration by organising systematic drugs screening in the French forces. However, for technical reasons, opiates are not concerned by this screening with the agreement of the people concerned. The estimated number of militaries who use an opiate substitute may be an approach of heroin consumption in the French forces. This study describes buprenorphine and methadone reimbursements made during 2007 by the national military healthcare centre to French militaries. MATERIAL AND METHOD: Each French soldier is affiliated to a special health insurance. The national military healthcare centre has in its information system, all the data concerning drug reimbursement made to French military personnel. This is a retrospective study of buprenorphine and methadone reimbursements made during 2007 by the military healthcare centre, to militaries from the three sectors of the French forces, and from the gendarmerie and joint forces. Only one reimbursement of one of these two drugs during this period allowed the patient to be included in our study. Daily drug dose and treatment steadiness profile have been calculated according to the criteria of the French monitoring centre for drugs and drug addiction. The criteria of the National guidelines against frauds have been used to identify misuse of these drugs. Doctors' shopping behaviour has also been studied. Finally, the nature of the prescriber and the consumption of other drugs in combination with opiate substitute have been analysed. RESULTS: One hundred and eighty-one military consumers of opiate substitute drugs (167 men and 14 women) participated. This sample included people from the three sectors of the French forces as well as from the gendarmerie and from the joint forces. The average age of the consumers was 26.6 years (20-42 years). The average length of service was 6.1 years (maximum 22 years service). One hundred and fifty-nine militaries had been delivered buprenorphine, 15 had been delivered methadone and seven had been delivered both. The prevalence of opiate substitute drug consumption by the militaries (52 per 100,000) is lower than in general population. According to the criteria of the National Healthcare Insurance, this population is not affected by abuse or fraud behaviour. Doctors' shopping behaviour is unusual. Opiate substitutes are prescribed by general physicians in 88% of issues. Only one prescriber was a military physician. An analysis of reimbursement of some drugs associated with opiate substitute has been made. The sampled military consume more psychoactive drugs (anxiolytics, antidepressants, hypnotics) than the French population under opiate substitution. CONCLUSION: In our observation, the military physician is almost always excluded the process of substitution. His/her different responsibilities of care, but also in determining the working aptitude, lead to dissimulation behaviour by the militaries. The difficulty for military physicians is to identify such consumption. They have to evaluate the capacity to work through a physical and psychological examination.

Analysis of the Uniform Accident And Sickness Policy Provision Law: lessons for social work practice, policy, and research.

The Uniform Accident and Sickness Policy Provision Law (UPPL) is a state statute that allows insurance companies in 26 states to deny claims for accidents and injuries incurred by persons under the influence of drugs or alcohol. Serious repercussions can result for patients and health care professionals as states enforce this law. To examine differences within the laws that might facilitate amendments or reduce insurance companies' ability to deny claims, a content analysis was carried out of each state's UPPL law. Results showed no meaningful differences between each state's laws. These results indicate patients and health professionals share similar risk related to the UPPL regardless of state.

Comparison and optimization of SAR-PAGE tests for erythropoietins in doping analysis.

Erythropoietins (EPOs) are substances listed in S2 of the World Anti-Doping Agency (WADA) Prohibited List and are used commonly by athletes to increase endurance performance. According to the current WADA Technical Documents, sarcosyl-polyacrylamide gel electrophoresis (SAR-PAGE) followed by western blotting to differentiate erythropoietins based on their molecular weights is the only method that can be used for both screening and confirmation of all types of erythropoietins. The efficiency of immunopurification and protein transfer is crucial for ensuring the selectivity and sensitivity of erythropoietin detection. Several comparisons and optimization of the SAR-PAGE tests were conducted in this study. We optimized the first blotting conditions and then compared different immunopurification methods based on their selectivity, repeatability, and sensitivity for both urine and blood analysis. Additionally, rapid procedures for both urine and blood analysis were established and compared. The two-step procedure at 1.0 mA/cm2 for 60 min followed by 1.56 mA/cm2 for 20 min increased the blotting efficiency compared with the commonly used constant current approach. Comparison of immunopurification revealed no significant difference in selectivity and sensitivity between the different methods. For other factors, such as operation complexity, time and cost, a StemCell® purification kit followed by single blotting and magnetic beads followed by double blotting are recommended for urine screening and confirmation, respectively. While magnetic beads and a MAIIA® kit followed by double blotting are recommended for both screening and confirmation of blood samples, respectively. To ensure high sensitivity and selectivity, double blotting is recommended for a rapid procedure for both urine and blood analysis.

Development of a multi-residue high-throughput UHPLC-MS/MS method for routine monitoring of SARM compounds in equine and bovine blood.

Selective androgen receptor modulators (SARMs) are a group of anabolic enhancer drugs posing threats to the integrity of animal sports and the safety of animal-derived foods. The current research describes for the first time the development of a semi-quantitative assay for the monitoring of SARM family compounds in blood and establishes the relative stability of these analytes under various storage conditions prior to analysis. The presented screening method validation was performed in line with current EU legislation for the inspection of livestock and produce of animal origin, with detection capability (CCß) values determined at 0.5 ng/mL (Ly2452473), 1 ng/mL (AC-262536 and PF-06260414), 2 ng/mL (bicalutamide, GLPG0492, LGD-2226, ostarine, S-1, S-6, and S-23), and 5 ng/mL (andarine, BMS-564929, LGD-4033, RAD140, and S-9), respectively. The applicability of the developed assay was demonstrated through the analysis of blood samples from racehorses and cattle. The developed method presents a high-throughput cost-effective tool for the routine screening for a range of SARM compounds in sport and livestock animals.

The implications of alcohol intoxication and the Uniform Policy Provision Law on trauma centers; a national trauma data bank analysis of minimally injured patients.

BACKGROUND: Alcohol intoxication may confound the initial assessment of trauma patients, resulting in increased use of diagnostic and therapeutic procedures, thereby increasing hospital costs. The Uniform Policy Provision Law (UPPL) exists in many states and allows insurance companies to deny payment for medical treatment for alcohol-related injuries. If intoxication increases resource utilization, these denials compound the financial burden of alcohol use on trauma centers. We hypothesized that patients injured while under the influence of alcohol require more diagnostic tests, procedures, and hospital admissions, leading to higher hospital charges. METHODS: The National Trauma Databank (2000-2004) was analyzed to identify adult trauma patients (age > or = 16 years) who were discharged alive, had a length of stay < or = 1 day and minor injuries (Injury Severity Score < 9), and were tested for blood alcohol. The study was confined to minimally injured patients to facilitate identification of unexpected resource use most likely attributable to alcohol use. Resource utilization was compared among patients who tested positive or negative for alcohol use. Results are presented as odds ratio (OR) with 95% confidence intervals (CI). RESULTS: Sixty-eight thousand eight patients met study criteria, of which 31,020 were positive for alcohol. Despite similar baseline characteristics, alcohol-positive patients required significantly more invasive procedures, including intubation (OR 4.16, 95% CI = 3.56-4.85) and Foley catheter insertion (OR 1.52, 95% CI = 1.39-1.67) as well as diagnostic tests (CT scan OR 1.16, 95% CI = 1.12-1.20). They were also less likely to be discharged from the emergency department (OR 0.61, 95% CI = 0.58-0.64), and more frequently required hospital (OR 1.64, 95% CI = 1.57-1.73) or intensive care unit admission (OR 1.82, 95% CI = 1.71-1.94). Mean hospital charges were $1,833 greater ($10,405 +/- 225 vs. 8,572 +/- 68). CONCLUSIONS: A significant amount of trauma center costs are primarily attributable to alcohol use rather than injury severity or outcome. The financial costs associated with alcohol use and UPPL-related cost-shifting to trauma centers is a significant burden to trauma centers. UPPL laws that penalize trauma centers for identifying intoxicated patients should be repealed in states where they exist.

[Comparison between analytic and anamnestic data about drug consumption among opiate addicts with substitutes therapy. A feasibility study]. / Comparaison des données analytiques et anamnestiques des consommations de drogues et psychotropes chez des usagers d'opiacés en traitement de substitution. Etude de faisabilité

In this feasibility study of an observational nature, we used the protocol 'AnalyTox-Op' to compare analytical data with anamnestic reports gathered from specialized drug addiction treatment centers. These data were collected from 32 drug addicts who were patients undergoing treatment with addictive drug substitutes or prescribed psychotropic drugs. Urine toxicology screens were performed using immunological methods followed by confirmation with more specific techniques, i.e. gas chromatography coupled with mass spectrometry (GC-MS) and liquid chromatography with diode array detection (HPLC-DB). While complete agreement between patient reports of drug consumption (obtained from a questionnaire) and analytical data was only observed in 13 out of the 32 cases, a very good concordance was seen with opiate substitutes (88% with methadone and high-dosage buprenorphine, combined) and legally prescribed psychotropic drugs. Of note, however, was the omission of illicit drug use in patient questionnaires, especially with cocaine (22%) and recreational opiates (22%), causing discordance in the comparison. This study is currently being expanded to include a large number of participants across the country with the aim of obtaining data under homogeneous conditions, verifying the discordance we found and determining its significance.

Rapid and simple procedure for the determination of cathinones, amphetamine-like stimulants and other new psychoactive substances in blood and urine by GC-MS.

In the last few years an increasing number of new psychoactive substances (NPS), with different chemical structures (of which 37% are stimulants), have been released into the illicit drug market. Their detection and identification in biological samples is hence of great concern. The aim of this work was to develop a high-throughput and rapid method for the determination of different classes of stimulants (amphetamine-type stimulants, cathinones, phenethylamines and ketamine analogues) from blood and urine samples using GC-MS. The proposed method allows the almost simultaneous derivatization and extraction of analytes from biological samples in a very short time, by using hexyl chloroformate as derivatization agent. The extraction of analytes was performed by Dispersive Liquid Liquid Microextraction (DLLME), a very rapid, cheap and efficient extraction technique that employs microliter amounts of organic solvents. The chromatographic method allowed for the separation of 26 stimulants including positional isomers (3-MMC and 4-MMC). The method was validated on urine and blood samples with the ability to detect and quantify all analytes with satisfactory limits of detection (LODs) ranging between 1 and 10ng/mL, limits of quantification (LOQs) between 2 and 50ng/mL, selectivity and linearity (5-1000ng/mL). The method was then applied to real samples from forensic cases, demonstrating its suitability for the screening of a wide number of stimulants in biological specimens.

Clinical Benefits of Direct-to-Definitive Testing for Monitoring Compliance in Pain Management.

BACKGROUND: The technical advantages of direct-to-definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu. OBJECTIVES: The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites. STUDY DESIGN: Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance. SETTING: The research took place at Brigham and Women's Hospital in Boston, MA. METHODS: The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined. RESULTS: False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases. LIMITATIONS: Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions. CONCLUSION: Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach. KEY WORDS: Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance.

The potential for accurately measuring behavioral and economic dimensions of consumption, prices, and markets for illegal drugs.

There are numerous analytic and methodological limitations to current measures of drug market activity. This paper explores the structure of markets and individual user behavior to provide an integrated understanding of behavioral and economic (and market) aspects of illegal drug use with an aim toward developing improved procedures for measurement. This involves understanding the social processes that structure illegal distribution networks and drug users' interactions with them. These networks are where and how social behaviors, prices, and markets for illegal drugs intersect. Our focus is upon getting an up close measurement of these activities. Building better measures of consumption behaviors necessitates building better rapport with subjects than typically achieved with one-time surveys in order to overcome withholding and underreporting and to get a comprehensive understanding of the processes involved. This can be achieved through repeated interviews and observations of behaviors. This paper also describes analytic advances that could be adopted to direct this inquiry including behavioral templates, and insights into the economic valuation of labor inputs and cash expenditures for various illegal drugs. Additionally, the paper makes recommendations to funding organizations for developing the mechanisms that would support behavioral scientists to weigh specimens and to collect small samples for laboratory analysis-by providing protection from the potential for arrest. The primary focus is upon U.S. markets. The implications for other countries are discussed.