In a Clinical Crossroads article featured in the March 6, 2013 issue of the Journal of the American Medical Association (JAMA), Dr. Dan Alford from Boston University School of Medicine (BUSM) and Boston Medical Center (BMC) suggests that prescription opioid abuse can be minimized by monitoring patients closely for harm by using urine drug testing (UDT), pill counts, and reviewing prescription drug monitoring program data when available.
Approximately 100 million Americans have chronic pain. The safe and effective use of opioids for the management of chronic pain is complex. Clinicians must balance the goals of relieving pain and suffering while not harming the patient resulting in addiction and overdose.
The JAMA article describes a 71-year old man who had been treated for chronic low back pain since 1981. After getting no pain relief from non-opioids, he achieved pain control with long-term opioids. However a UDT found no opioid in his system on two occasions and his opioid was discontinued. He explained that he occasionally drinks alcohol and does not take his opioid medication when doing so.
“When a patient exhibits behavior for opioid misuse, the clinician should first confirm that the UDT was accurate. If confirmed, the clinician should interview the patient considering the full differential diagnosis for the behavior of concern. Once the etiology has been determined, a change in treatment plan may occur,” explained Alford, an associate professor of medicine at BUSM and the Director of the Addiction Medicine Fellowship program at BMC.
Alford stresses that monitoring for benefit includes measuring improvement in pain, function and quality of life. Monitoring for harm includes detecting opioid misuse through UDT, pill counts and use of state prescription drug monitoring programs.
Decisions to continue or discontinue opioids should be based on the risk-to-benefit ratio. “In this case of the patient with no opioid in his UDT if he was benefiting but taking less than prescribed, I would inquire about the status and safe storage of his extra medication. I would decrease his dose and schedule close follow up with random pill counts and UDT. If there was too much risk (misuse such as diversion) despite benefit, I would discontinue his opioid therapy as was done in this case,” added Alford.