Monitoring Patients Receiving Opioids for Chronic Non-cancer Pain
Urine Toxicology Tests are becoming more common to monitor patients receiving chronic opioid analgesics. In pain management, drug tests can be useful, but they need to be used thoughtfully. The plan and reasoning for drug testing for these patients needs to be discussed thoroughly with the patient. Some patients may find drug tests intrusive; others accept the practice. Drug tests tend to be associated with drug abuse treatment and some patients may be offended when asked to participate in drug testing as part of pain treatment.
Drug tests do not monitor therapeutic drug levels; they provide information regarding medication adherence to the prescribed medication and/or the ingestion of illicit drugs. The only exception is the use of serum methadone levels. If the drug test shows the use of illicit drugs in addition to the prescribed medications, the patient needs to be educated regarding the danger of using illicit substances and opioid pain medications and that substance abuse is not helpful to long-term pain management. Some patients may need to be referred to specialists in both addiction and pain management. If the patient is receiving medication-assisted treatment, the dosage may need to be increased.
An important concept of substance abuse treatment is that one failure (e.g., relapse, leaving treatment), or even multiple treatment failures, is not a reason to deny further treatment to a patient. The practitioner should expect relapses and be prepared to respond in a therapeutically appropriate manner. The patient may not be able to achieve recovery after one, or even several, treatment periods. SUDs are chronic, relapsing conditions that often need repeated interventions or treatments before a patient is stabilized. The practitioner should not expect that patients with problems related to alcohol and drug use will have any less difficulty than other patients in making significant lifestyle changes.
Unless a practitioner is testing for all substances (which is virtually impossible), heavy reliance on drug tests can be misleading in monitoring abstinence. Patients can abstain from their substance of choice while using other substances that may not be part of a particular drug test panel. Practitioners should test not only for the patient’s substance of choice, but also other commonly abused drugs.