Last year, I wrote a column for Medical Laboratory Observer on the dual healthcare epidemics of chronic pain and prescription medication misuse. I suggested that while opioid prescription drugs are vital to helping more than 100 million people in the United States manage their chronic pain, the healthcare industry also needs to do a better job of preventing the misuse of these and other powerful prescription medications.
I also argued that those of us in the laboratory industry can play a role in addressing these new health crises. Advances in laboratory testing for metabolites of drugs in urine provide physicians with an important new tool for objectively gauging appropriate drug use. And we are very close to being able to assess how well a patient will metabolize a drug based on genetics. As I pointed out a year ago, we also need greater social awareness of the dangers of drug misuse and clearer regulations, particularly for clinicians.
Since that time, a number of developments suggest government and the healthcare industry are moving proactively to combat prescription drug misuse. In June, the Office of the National Coordinator for Health Information Technology launched a pilot program to facilitate access to patients’ prescription drug histories to healthcare professionals in ambulatory and emergency settings.1 A month later, a bipartisan bill was introduced to Congress that would require R&D for pain medications to adopt abuse-deterring safeguards. The bill represents “the broadest congressional attempt at curbing the nation’s prescription-drug problem” to date, according to The Wall Street Journal.2
Meanwhile, New York State, a leader in the use of information technology in healthcare, passed a comprehensive legislative package which, in part, requires prescriptions to be filed electronically to prevent tampering, which occurs all too frequently with written scripts.
In addition, health plans are introducing policies requiring physicians to more closely manage patients, such as by limiting medical refills. Payers are also driving participation in state prescription monitoring programs (PMPs), as well as prospective, concurrent, and retrospective Drug Utilization Reviews to minimize the occurrence of inappropriate use of opioids and other addictive medications.
These are positive developments. But more needs to be done to curtail the misuse of commonly abused medications.
One of the steps that must be taken, as I suggested in this column a year ago, is greater education in the dangers of prescription drug misuse. Too many patients incorrectly believe prescription medications are less dangerous than illicit drugs. And based on my experience, too many physicians are unaware of the tools at their disposal (urine testing being one of them) to clinically manage patients to minimize the threat of misuse.
There also seems to be a widely held belief among physicians that only certain types of patients are likely to misuse prescription medications. New research shows that simply is not the case.
In the first half of 2012, Quest Diagnostics released a report which detailed an analysis of nearly 76,000 laboratory tests for prescription drug use for 2011. The analysis was based on results of the company’s prescription drug monitoring services, which we introduced to physicians about 18 months ago. The services build on our employer drug testing services and the Quest Diagnostics Drug Testing Index, a series of publicly available reports of workplace drug positives.
Our findings demonstrated that the vast majority of Americans tested misused their prescription drugs, including potentially addictive pain medications like oxycodone, as well as central nervous system depressants such as Vicodin and the amphetamine Adderall. Specifically, more than three in five patients, or 63%, tested through Quest Diagnostics’ clinical laboratories were inconsistent with clinician orders.3
Misuse took the form of combining prescription drugs with other drugs without a clinician’s oversight or not taking medications that were prescribed. In other cases, misuse was found in tests that showed patients had taken drugs—but not the ones the doctor had indicated for the patient.
The most striking finding from our study was that everyone was at risk. High rates of misuse were found across both genders and all ages, income levels, and participation in private and government health plans. Importantly, pain controlling opioids, which hold the greatest potential for addiction and other forms of abuse, represented the bulk of the medications prescribed and tested for in the analysis.
Our study had certain limits. These included lack of access to medical records with which to corroborate our findings and the prospect that physicians only tested those patients they believed were misusing their medications. Yet, the large, nationally representative population suggests the findings are a good barometer of patterns of misuse with other patients in the U.S.
Put simply, clinicians must assume ALL of their patients on prescription meds are at the risk of misuse. Periodic laboratory testing, and tandem mass spectrometry testing in particular (the method used to confirm all positive results in our study), provide an objective measure of drug adherence that can aid physician monitoring. Particularly with pain medications, LC-MS/MS is often preferred for medication monitoring because of its improved sensitivity and specificity. Studies have proven that due to tandem mass spectrometry’s secondary analytical separation step, sample analysis is freer of interferences, minimizing “unable to confirm” samples.4
And repeat testing appears to be an effective tool. The study showed that among all patients tested 30 days or more after an initial screen, the number of patients with inconsistent results declined by 10%. For those only taking pain medications, the drop was even more dramatic, reducing the number of patients with inconsistent use by 17%.
The study’s findings have important ramifications. If, as the findings show, anyone is at risk of misuse, education programs must focus on previously neglected groups, such as older patients (about 60% showed evidence of misuse in our study) and the financially well-to-do (who were more likely to combine medications without a clinician’s oversight).
We also need physicians to be more proactive in monitoring for misuse, not only by subjective methods like patient interviews but through objective measures. Urine testing is recommended by several medication associations, and for good reason: it is arguably the only reliable objective measure of whether a patient is taking medications as prescribed.
Above all, as healthcare providers who want to serve the best interests of our patients, we must be committed to providing test and service innovations that will help clinicians curtail the prescription drug epidemic. There is much more work to be done.
References
- U.S. Department of Health and Human Services, http://www.hhs.gov/news/press/2012pres/06/20120621c.html, June 21, 2012. Accessed July 31, 2012.
- U.S. News: Bill aims to deter painkiller abuse. Martin TW. The Wall Street Journal. July 19, 2012.
- Quest Diagnostics Health Trends™ Report: Prescription Drug Misuse in America, Laboratory Insights into the New Drug Epidemic. 2012.
- Mikel C, Pesce A, West, C. A tale of two drug testing technologies. Pain Physician. 2010;13(1):91-92.
Jon R. Cohen, MD, is senior vice president, chief medical officer, and director of hospital services for Quest Diagnostics. In 2010, Modern Healthcare named him one of the nation’s top 50 most powerful physician executives.
