by Steven D. Passik, PhD, Adam Rzetelny, PhD and Kenneth L. Kirsh, PhD*
The NFMCPA expresses appreciation for the contribution from these distinguished authors to discuss important topics of urine drug tests and stigmatization of people in the setting of chronic pain.
Introduction – A Personal Note
One of the authors (Dr. Steven D. Passik) would like to begin this piece describing his recent experience with chronic pain and the risk assessment involved in opioid therapy.
But it isn’t just the possibility of permanent damage and the need for an even bigger surgery that finally moved me along the trajectory to patient-hood. It has been amazing for me to learn on a personal level how even a very specific pain that only comes on with certain movements can make you feel so unwell. It has been particularly bad for me at night. I wake up unrested and feel bad enough in the morning that I skip the visit to the gym (even for walking/running on the treadmill as weights have been out of the question). I have gained a lot of weight, making me feel fat and old.
So what does all this have to do with urine drug testing?
I wouldn’t have relayed this story here had it not been for an interesting experience I had as a result of this. I finally got in to see an orthopedic surgeon. I met him, his fellow, and several members of the staff. All were extremely professional and friendly. Several made an effort to prepare me for five months of painful recovery. The availability of pain medication was mentioned several times. But, and I don’t say this to be critical of these specific practitioners, this was clearly about my shoulder joint. I was never asked who I am as a person; never asked what I do for a living and most importantly never asked anything about a history of risk factors for addiction (the exceptions were 2 items on the medical history form that were filled out at home about smoking – something likely of concern in reference to surgical wound healing; and alcohol – something they might be interested in to know before anesthesia or perhaps for concerns about withdrawal if I stopped abruptly before the procedure). No questions were asked about past experiences with opioid pain medications. And I was fairly sure that none of the above mentioned questions were related in their minds to the potential risks of being exposed to opioids in my post-operative pain management.
I am a pretty typical looking, pudgy Caucasian middle-aged male. I was clean shaven and neatly (but casually) dressed. Overall, one might suppose I don’t “look like an addict.” And the truth is, because I am aware of my personal and family history, I have absolutely no fear of addiction related to post-operative opioid exposure.
But this episode made me realize that patients are often on their own when it comes to the assessment and management of addiction risk in these situations. I would not want to live in a world wherein people have painful injuries and painful things done to them and opioids are not offered for their acute and even chronic pain. It is clear that the occasional mentions of pain medication were signs of a certain humanity that is built in to their “standard operating procedures” (SOP). If I had reason to be concerned about my possible illness-of-fit to their SOPs, it would have been “on me” as they say. But not everyone has the vocabulary to take on this topic in a rushed discussion with their medical team; nor does everyone possess the insight or the capacity for honest self-reflection on their risk level or their use of medications. Some would be too fearful of being left in untreated pain to ask for special management knowing that they had an addiction history. And I am not sure that every medical group in the world would know what to do with the person at heightened risk even if this conversation took place.
Risk Management ALL of this said, this is why we believe that people with pain need to be educated about the need for risk management in opioid therapy and then to embrace it…in fact, demand it. In the interest of full disclosure, we work for a company that provides urine drug testing (UDT) to pain management and many other types of practices. Also in the interest of full disclosure, SDP and KLK practiced for nearly 25 and 20 years respectively, always as part of teams that used UDT, and we wrote our first paper on it more than a decade ago - long before coming to this industry. Now we know that many of you reading this may have had bad experiences with UDT. You may have had it introduced in a threatening, abrupt and non-helpful way. You have been told or felt threatened that if it isn’t “clean” you might be discharged. Some of you probably feel you have been tested too often for your level of risk and record of prior adherence and some of you have been made to feel like addicts or criminals (in not only this, but many situations, i.e., your torturous visits to the pharmacy).
There are risks in being exposed to medications that have abuse potential or can be habit forming. Indeed, it takes 3 things to create addiction – an exposure to a potentially abusable drug in a vulnerable person at a vulnerable time. If you are taking opioid medications then of course you are having such an exposure. If you have pain, you are more than likely at a highly stressful and depressing, vulnerable time. Do you have vulnerabilities? Is there a history of addiction in your past? In your family? Are you under 35? Are you struggling with depression or anxiety? Do you have a history of sexual or other trauma? Do you smoke? Many of us have a smattering of these vulnerabilities. For some of us they will be active as soon as we are exposed to certain drugs or foods or experiences (gambling or sex), and we may lose control of our use. For others, only when we are even more stressed than usual with our pain will we lose control. We have seen people in our careers who were using their opioids as directed only to suffer a loss and then suddenly they are in the clinic asking for a renewal of their prescription early. For some people, taking the occasional extra pill is an innocent act, very unlikely to lead to loss of control and for others, it is a slippery slope. We have to know ourselves, be honest about why we are taking the extra pill (because of pain or injury or for the seeking of a euphoric feeling or “high” and we need to have the monitoring and tools to help us to be honest with ourselves and to give our doctor the specific, objective information she needs to advocate for us and know if we are safe or not.
Urine Drug Testing Accurate and specific UDT is a monitoring tool that can be viewed like the scale when you are dieting. It keeps you honest. It’s a reminder. It influences the choices you make. On the opposite side, it is an objective measure your doctor can use to try to help you stay on track and help him/her to advocate for you to receive pain medication when needed (especially helpful when loved ones, friends or employers may question why you take “those” medications). Some of us might need to step on the scale more often than others to keep control of our eating and food choices. In either case, UDT is a tool that can provide your healthcare practitioners with objective information to be used to help in your care.
Unfortunately in its initial importation into pain management, UDT was probably used in a fashion that had not evolved far enough from its roots. UDT started out in the vocational, forensic and military worlds. It started out with a certain method (so-called, immunoassay [IA] testing that typically only tests for classes of drugs) and a stigmatizing mindset (“catching bad people doing bad things”). It was still too much about “gotcha,” and there had not yet been a full evolution of the method or the mindset to make it feel personally useful for clinicians treating people with pain. People with pain should want to be tested like people with pain, in other words, like people with a medical condition on specific helpful medicines and not like a risky truck driver or a person on parole. However, with the development of more sophisticated mass spectrometry testing (either gas chromatography with mass spectrometry [GC-MS] or liquid chromatography and tandem mass spectrometry [LC-MS/MS]), a clinically useful method that also detects specific drugs and metabolites prescribed to people with pain and delivering results in timeframes that make them useful to pain doctors and their patients, this evolution has been enabled. Recalling the weight analogy, if all the scale said is “you weigh a lot” or “you weigh a little” the value would be diminished. People with pain can now be tested with great accuracy that tells their doctors specifically what they are taking (or not taking) and some suggestion of how their body is metabolizing it. And perhaps most importantly, with these developments comes the opportunity for the mindset around UDT to evolve as well, so that being tested is experienced as a medical tool that helps clinicians / doctors optimize patient care, while maintaining their dignity.
The challenge for healthcare practitioners going forward is how to use these improved but more costly methods in a fashion that is tied to each patient’s level of risk so as to maximize the benefit of having this information but without overusing it. In today’s world, where we move around or change doctors etc., having a detailed and objective record of our adherence in our medical records is becoming a necessity if one has to interface with employers, the legal system, or even to convince a new practitioner involved in our care to overcome the growing reticence in the community and continue ones medications if they have been working.
SDP has had his surgery and thus far has been the recipient of excellent post-operative pain management. His experience helped us to realize how people with pain must take this on themselves in large part. Advocate, communicate, ask for special treatment, be honest with yourself and your provider.
*Steven D. Passik, PhD1,2 Adam Rzetelny, PhD1 Kenneth L. Kirsh, PhD1,2
1: Millennium Laboratories, 16981 Via Tazon, San Diego, CA 92127 2: Millennium Research Institute, 16980 Via Tazon, San Diego, CA 92127
Photograph courtesy of NEI--Rhoda Baer, photographer