Safe opioid prescribing demands that we, the prescribing doctor, make sure that the patient getting the opioids is getting benefit from them. Benefit means decreased pain, increased function and no side effects and no abuse. Opioids are used for any type of pain, whether cancer pain, low back pain, pain from disc herniations, facet disease, spondylosis, spondylolisthesis, arthritis of the spine, sacroiliac disease, complex regional pain syndrome or reflex sympathetic dystrophy, fibromyalgia, irritable bowel syndrome or chronic fatigue. This increased function should occur with any of these pain types.
There are many ways of monitoring opioid use. The first step is to listen to the family. They can tell better than the doctor if there is any abuse of the medications or other drugs.
Another simple way of monitoring is to ask what one can do with the opioids that cannot be done without them. Another is to ask what percent pain relief you get from the opioids. It should be clear that if someone cannot do anything more with the opioids and only has 20% relief, what is the point of providing the opioids? An interesting sidebar is that patients often report 50% relief and then rate their pain 8/10. This reporting raises the interesting question of what baseline pain, on a 10 point scale, are you taking 50% from to end up with 8? The answer is that the numbers don’t work.
We also look at California’s prescription monitoring program, CURES, which tells us where one has been getting Scheduled medications.
Pill counts are occasionally useful. Some put great value in them. I only use them when patients regularly run out early. If a patient comes in two days before their meds are due to run out, says they have a two day supply and agree that the next script will last the two days plus the thirty days of the script, or thirty-two days, I do not see the advantage of a pill count.
Urine drug testing is one of the most valuable tools we have. It can be done several ways, either at the office only, or sent out for specialized lab testing, using a mass spectrometer, which is very specific. The immunoassay testing done in the office can result in false positives; the mass spec will not. There can be confusion also about alcohol, with false positives being possible in people who use a lot of hand sanitizer. Fortunately, the mass spec can provide useful information to differentiate between hand sanitizer and alcohol use.
Urine drug testing can also be a source of abuse. It is a huge industry, with testing running over $1000 per specimen, depending on how many different drugs are tested for. Some doctors use urine drug testing a major income sources, which is sometime legitimate and sometimes not. Some of the testing labs have engaged in kickback schemes. Sometimes doctors who are not providing the opioids get complete urine drug screens at every visit, a practice which makes no medical sense. We at the Helm Center for Pain management want to see that you get the right care at the right price. We do use drug testing extensively, but only want to see the appropriate tests being performed. Urine drug testing is important and should be implemented by any practice prescribing opioids. Properly done, it will benefit the patient, the practice and the payer