Patients being treated for chronic pain stray from their opioid regimen, voluntarily or involuntarily, for several reasons. In some cases, patients want to remain adherent to their regimen but become addicted to the opioids accidentally. "Sometimes patients get in trouble and they can't help abusing," says Harry Leider, MD, an internist and chief medical officer for Ameritox, a company focused on medication monitoring solutions. "At that point, drug monitoring programs are really about patient safety and education."
Other patients choose not to adhere to their treatment pathway, either by taking too many on purpose or taking too few and illegally selling or giving away the surplus. There are several implications of inappropriate opioid use that weigh heavily on patients and society. Dr. Leider discusses how physicians can detect diversion and help keep opioid users safe.
1. Lowering the cost of chronic pain healthcare. A recent Congressional hearing on "Costs of Prescription Drug Abuse in Medicare Part D Program" points toward medication monitoring as a potential solution for improving adherence to pain medication, preventing drug diversion and helping lower national healthcare costs.
New data published in The American Journal of Managed Care suggests patients who were likely non-adherent to their opioid therapy for chronic pain had 14 percent higher healthcare costs and 35 percent more hospital days than opioid therapy patients who may be adherent. Adherent patients also cost approximately 12 percent less than non-adherent patients, so encouraging adherence represents a significant opportunity for cutting healthcare costs.
"Patients who are on narcotics cost about $23,000 per year, and $3,000-plus more if they are likely not compliant," says Dr. Leider. "Patients taking medications as directed is a big deal in terms of quality of care and savings for the healthcare system."
2. Identifying and preventing non-adherence. There are some factors that are associated with higher risk for likely non-adherence that physicians can identify, such as unemployment or drug abuse. In all patients, especially those with high risk factors for abuse, there are a few steps physicians can take to prevent non-compliance:
• Assess patient history to identify and track potential risk for abuse.
• Track ER visits to make sure patients are not going there for extra pain medication.
• Have patients sign a pain management agreement to follow rules, such as only receive pain prescriptions from one physician, only fill prescriptions at one pharmacy, notify the physician about taking any new medications.
• Take periodic urine samples for drug testing.
Dr. Leider believes the high costs associated with non-adherence will lead other stakeholders in the healthcare system, such as managed care companies, to provide additional support to physicians dealing with potential abusers. "When payors see financial statistics, they will most likely pay more attention to opioid abuse and support clinicians in providing reinforcement and feedback to patients about the importance of adherence," he says.
3. Educating patients on drug tests and abuse. If the patient takes an overdose of opioids, the aftermath could be life-altering or fatal. High-dose regimens of opioid consumption, even if the patient is adherent, could make them a poor candidate for surgery later because it takes such a large volume of potent pain medication to numb the surgical site, says Dr. Leider. Some patients may feel offended or invaded by the suggestion of drug tests, but educating them on test objectives may curb some of the resistance.
"Patients need to be educated so they don't think the tests are a 'gotcha' type of thing; rather, the tests are a strategy to keep them safe," says Dr. Leider.
He cautions physicians to test all patients, even those who aren't at risk or who physicians think wouldn't diverge because all patients are at some risk. A study examining clinicians' judgment on which patients were abusing drugs compared with the results of monitoring tests showed that clinicians were wrong about 30 percent of the time, says Dr. Leider.
"The data clearly shows that clinicians can't necessarily know about their patients' risks and behaviors," he says. "Despite the guidelines and consensus we have about drug monitoring, many physicians don't do it because they believe they know their patients or that they are good clinical judges and they don't need an additional test to monitor adherence. In this case, physicians might be missing a critical problem that will only get worse."
4. Cheating on drug tests. Administering drug tests to all patients is a good first step toward monitoring compliance. However, there are several ways patients can cheat on traditional drug tests. These tests only detect whether patients consumed their medication within the past 24 hours — not how much was consumed or whether it was also consumed in the days prior to the test. Patients can easily take just one pill on the day of the test and sell the rest, or take too many pills within 24 hours of the test and still pass.
"You'd be surprised at how much information there is on the Internet about ways patients can abuse the system," says Dr. Leider. "They can surf the web and figure out how to game the test, so be aware of that."
5. Fixing problems with traditional drug tests. There are some companies, such as Ameritox, that are working on solutions for fixing the problems with traditional drug tests. Ameritox has proprietary technology — Rx Guardian CD — which can identify the amount of opioids in the patients' system and compare the results with a database of adherent patients to help physicians ensure compliance. "We developed this technology based on the idea of comparing the patients' drug levels in the urine, adjusted by a formula for hydration and body weight, with patients who we know are taking the medication correctly," says Dr. Leider. "By doing this, we can give physicians feedback about whether it looks like their patients are taking the right amount based on the prescribed regimen."
After submitting the test, it usually takes four or five days to receive the results, which come in a numeric score. "Pain medication monitoring has really become a standard of care, and the more information we can provide to clinicians who are dealing with chronic pain problems, the more we can help them take care of patients," he says.
6. Helping patients who abuse. Once an abuser is identified, it can be challenging for the physician to provide all the necessary care. "I think the biggest challenge if you find out a patient does have a problem with substance abuse, it can be time consuming to get them help," says Dr. Leider. "You have to talk with these patients, make sure they go through substance abuse programs and provide them with resources about preventing further drug abuse."
In some schools of thought, all this trouble isn't worth the return and restricting access to pain medication is the best solution. However, Dr. Leider disagrees because there are several ways medical professionals can monitor opioid use without taking medications away from their patients.
"Most of the experts believe that the problem can be solved by physicians being vigilant about who they prescribe to," he says. "It's a challenge for our healthcare system to deal with people who are in trouble, but overtly restricting access to the medications isn't a solution because you still have people suffering."
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Other patients choose not to adhere to their treatment pathway, either by taking too many on purpose or taking too few and illegally selling or giving away the surplus. There are several implications of inappropriate opioid use that weigh heavily on patients and society. Dr. Leider discusses how physicians can detect diversion and help keep opioid users safe.
1. Lowering the cost of chronic pain healthcare. A recent Congressional hearing on "Costs of Prescription Drug Abuse in Medicare Part D Program" points toward medication monitoring as a potential solution for improving adherence to pain medication, preventing drug diversion and helping lower national healthcare costs.
New data published in The American Journal of Managed Care suggests patients who were likely non-adherent to their opioid therapy for chronic pain had 14 percent higher healthcare costs and 35 percent more hospital days than opioid therapy patients who may be adherent. Adherent patients also cost approximately 12 percent less than non-adherent patients, so encouraging adherence represents a significant opportunity for cutting healthcare costs.
"Patients who are on narcotics cost about $23,000 per year, and $3,000-plus more if they are likely not compliant," says Dr. Leider. "Patients taking medications as directed is a big deal in terms of quality of care and savings for the healthcare system."
2. Identifying and preventing non-adherence. There are some factors that are associated with higher risk for likely non-adherence that physicians can identify, such as unemployment or drug abuse. In all patients, especially those with high risk factors for abuse, there are a few steps physicians can take to prevent non-compliance:
• Assess patient history to identify and track potential risk for abuse.
• Track ER visits to make sure patients are not going there for extra pain medication.
• Have patients sign a pain management agreement to follow rules, such as only receive pain prescriptions from one physician, only fill prescriptions at one pharmacy, notify the physician about taking any new medications.
• Take periodic urine samples for drug testing.
Dr. Leider believes the high costs associated with non-adherence will lead other stakeholders in the healthcare system, such as managed care companies, to provide additional support to physicians dealing with potential abusers. "When payors see financial statistics, they will most likely pay more attention to opioid abuse and support clinicians in providing reinforcement and feedback to patients about the importance of adherence," he says.
3. Educating patients on drug tests and abuse. If the patient takes an overdose of opioids, the aftermath could be life-altering or fatal. High-dose regimens of opioid consumption, even if the patient is adherent, could make them a poor candidate for surgery later because it takes such a large volume of potent pain medication to numb the surgical site, says Dr. Leider. Some patients may feel offended or invaded by the suggestion of drug tests, but educating them on test objectives may curb some of the resistance.
"Patients need to be educated so they don't think the tests are a 'gotcha' type of thing; rather, the tests are a strategy to keep them safe," says Dr. Leider.
He cautions physicians to test all patients, even those who aren't at risk or who physicians think wouldn't diverge because all patients are at some risk. A study examining clinicians' judgment on which patients were abusing drugs compared with the results of monitoring tests showed that clinicians were wrong about 30 percent of the time, says Dr. Leider.
"The data clearly shows that clinicians can't necessarily know about their patients' risks and behaviors," he says. "Despite the guidelines and consensus we have about drug monitoring, many physicians don't do it because they believe they know their patients or that they are good clinical judges and they don't need an additional test to monitor adherence. In this case, physicians might be missing a critical problem that will only get worse."
4. Cheating on drug tests. Administering drug tests to all patients is a good first step toward monitoring compliance. However, there are several ways patients can cheat on traditional drug tests. These tests only detect whether patients consumed their medication within the past 24 hours — not how much was consumed or whether it was also consumed in the days prior to the test. Patients can easily take just one pill on the day of the test and sell the rest, or take too many pills within 24 hours of the test and still pass.
"You'd be surprised at how much information there is on the Internet about ways patients can abuse the system," says Dr. Leider. "They can surf the web and figure out how to game the test, so be aware of that."
5. Fixing problems with traditional drug tests. There are some companies, such as Ameritox, that are working on solutions for fixing the problems with traditional drug tests. Ameritox has proprietary technology — Rx Guardian CD — which can identify the amount of opioids in the patients' system and compare the results with a database of adherent patients to help physicians ensure compliance. "We developed this technology based on the idea of comparing the patients' drug levels in the urine, adjusted by a formula for hydration and body weight, with patients who we know are taking the medication correctly," says Dr. Leider. "By doing this, we can give physicians feedback about whether it looks like their patients are taking the right amount based on the prescribed regimen."
After submitting the test, it usually takes four or five days to receive the results, which come in a numeric score. "Pain medication monitoring has really become a standard of care, and the more information we can provide to clinicians who are dealing with chronic pain problems, the more we can help them take care of patients," he says.
6. Helping patients who abuse. Once an abuser is identified, it can be challenging for the physician to provide all the necessary care. "I think the biggest challenge if you find out a patient does have a problem with substance abuse, it can be time consuming to get them help," says Dr. Leider. "You have to talk with these patients, make sure they go through substance abuse programs and provide them with resources about preventing further drug abuse."
In some schools of thought, all this trouble isn't worth the return and restricting access to pain medication is the best solution. However, Dr. Leider disagrees because there are several ways medical professionals can monitor opioid use without taking medications away from their patients.
"Most of the experts believe that the problem can be solved by physicians being vigilant about who they prescribe to," he says. "It's a challenge for our healthcare system to deal with people who are in trouble, but overtly restricting access to the medications isn't a solution because you still have people suffering."
Related Articles on Pain Management:
Study: Spinal Cord Stimulation Effective for HIV Neuropathy
Pain Center of Arizona Opens New Clinic in Phoenix
Pain Physicians: What is the Biggest Factor Contributing to Your Practice's Profitability?