Kurt W.G. Matthies is a writer and disabled former engineer who lives with the pain of severe chronic spine disease. He comments on chronic pain issues for National Pain Report. You can follow Kurt @kwgmatthies on Twitter.
As a pain patient on chronic opioid therapy (COT), I dread the regular urine drug test (UDT).
Yes, I take my prescriptions as directed. I don’t use street drugs, and even though I live in Colorado, I don’t smoke marijuana.
But as a peer counselor to others in chronic pain, I’ve heard from hundreds of fellow patients, once treated with COT who now are denied opioid analgesics because they failed a UDT.
Even though I follow the rules, I live with an underlying anxiety that my medications will be taken from me due to an error in interpretation of my UDT. I believe that most, if not all chronic painers share this particular form of PTSD.
Pain treatment has changed in the past few years. To address disturbing reports of a trend in increased opioid-related deaths, in 2009 the Federation of State Medical Boards recommended changes in the standards of care for patients receiving COT. Those changes included the use of periodic UDT and recommended that patients sign controlled substance agreements (CSA) to monitor patient compliance and minimize risk. Today, everyone on COT now signs a CSA promising to follow specific rules and submits to periodic UDTs.
For many, failure of a single UDT can mean forfeiting COT and too many patients are suffering because they’ve lost access to opioid analgesics for this very reason. The shame of it is that many patients lose their COT because of inaccurate or misinterpreted UDT results.
The good news is that a new company, Remitigate, LLC, has developed the first in a family of apps – UDTapp – that helps prescribers interpret unexpected UDT results. Available for both Android and iPhone, UDTapp compares data from a patient’s medication list with a database describing the complex pharmacokinetics of pain medications and illicit drugs, considers dosages and other parameters, and presents the prescriber with a simple interpretation of the results, along with a list of recommended actions for mitigating any problem with unexpected results.
Suppose you’re a patient prescribed Zohydro ER 10mg twice a day and Omaprazole 20mg every morning. On your next doctor visit, you provide a UDT sample. Later that week, you get a call from your doctor’s office. He wants to talk with you about your UDT, which has come back negative for opioids and positive for cannabinoids.
Cannabinoids are natural alkaloids found in only one plant – marijuana. Cannabinoids in your urine can mean you’ve been smoking marijuana, which your CSA may prohibit. You take your Zohydro twice a day, just like it says on the bottle. If you didn’t, you couldn’t get out of bed. But they said your report was negative for opioids – how could that be?
If you’re lucky, your doctor will sit you down for a heart-to-heart about taking your meds properly and “what’s this about your marijuana use?” No, you don’t smoke “pot” so you deny any marijuana use, but how do you prove a negative? Also, how do you prove that you’re taking your pain meds as prescribed if the test says that you aren’t – why isn’t there any opioid in your urine?
If you have a good relationship with your doc, maybe he’ll let it go with “OK, but if I ever see this again, then we’re going to have to reconsider your treatment options.”
In this scenario, I noted that you’re lucky to have a good doctor. Some patients receive a certified letter dismissing them from the practice. No warning or explanation – just the letter. You’ve been cut off from your medications because of a UDT that to you makes no sense at all.
Imagine this nightmare! You feel betrayed, confused, and most of all, frightened. Where can I get pain medicine now? Can I ever get pain medicine again? You might also feel outrage at being accused of smoking marijuana. How did this happen, and what if it happens again?
Anyone who’s experienced opioid withdrawal deeply understands this fear, and it is medically justifiable.
Pain expert Dr. Forest Tennant, MD, DrPH, has written “opioid withdrawal can be a serious, suffering state in pain patients… When opioid withdrawal begins, pain may flare with its attendant hypertension, tachycardia, vasoconstriction, and other manifestations of a hyper-aroused autonomic nervous system. Pain patients with underlying cardiovascular and neurologic disorders can even perish if suddenly deprived of opioids.”[i]
Let’s return to your scenario, with your compassionate and ethical doctor who wants to do the right thing. He may also feel betrayed. He’s been taking you at your word all this time and now has received information indicating that you’re misusing Zohydro and using marijuana without his knowledge. What’s he to think?
Outside of the realm of feelings, this false-negative / false-positive UDT issue has medical implications in today’s pain medicine community and is becoming a growing problem for today’s chronic painers on COT.
A so-called ‘dirty’ UDT has the potential for ruining a doctor-patient relationship, and can haunt the patient as they try to seek out a new provider that insists on receipt of your previous medical records. Many people in pain have already been denied opioid therapy because of a failed UDT.
Many people are treated for pain by their PCP or GP. If a patient has a medical problem other than pain, like diabetes or hypertension that requires regular treatment, how does a ‘dirty’ UDT interfere with future treatment?
This scenario illustrates why UDTapp is such an important development in the technology of pain management. It serves both prescribers and patients. UDTapp is a peacemaker that can solve anomalies in UDT as illustrated in our example before they generate feelings of mistrust and animosity in the doctor-patient relationship.
Let’s extend our scenario by adding UDTapp. You are prescribed Omeprazole 20mg once a day and Zohydro 10mg twice a day. Your UDT comes back negative for opioids and positive for cannabinoids.
UDTapp remembers a patient’s medication list and after UDT results are entered will present the prescriber with an analysis of those results which might look like this:
UDTapp recommends a more sensitive test, called chromatography, to test for the presence of opioids, and advises the prescriber that low dose semi-synthetic opioids are often be missed by less sensitive (and less expensive) UDTs that use a technique called Immunoassay (IA). Most medical offices use IA to monitor their patients. And some insurance companies refuse to pay for the more expensive confirmatory testing.
UDTapp knows that omeprazole (and other medications, including some that are available OTC like ibuprofen and naproxen), can cause false positive UDT results for cannabinoids
Doctors who trust their patients, and are informed by UDTapp, can feel assured that their patient is not smoking marijuana – a result of which UDTapp recommends be confirmed with chromatography in the unique case presented.
With information provided by UDTapp, a prescriber can retest for opioids and cannabinoids with chromatography, and likely avoid that uncomfortable conversation about “your marijuana use.”
Remitigate’s founder and the force behind UDTapp is Dr. Jeffrey Fudin, B.S., Pharm.D., FCCP, FASHP . Jeff is a pharmacist, professor, and consultant whose specialty is pain management. Remitigate, LLC is Dr. Fudin’s first entrepreneurial effort. As Dr. Fudin explained in a recent interview, “we combined two words – remit and mitigate – to come up with the name Remitigate. Remit means ‘to forgive’ and mitigate means ‘to solve or prevent a problem’.”
“I wanted to create a tool to help both doctors and patients solve problems that arise with UDTs,” continued Dr. Fudin, “to avoid unnecessary confrontation and blame, but also to educate the provider to navigate and understand these complex issues with reduced stress.”
A demonstration copy of UDTapp will soon be available on the company’s website at Remitigate.com, where doctors and patients can see the app in action.
Remitigate, LLC intends to develop a PC version that will interface to popular medical records software systems for direct entry of UDT analysis into a patient’s chart, and to provide patient handouts.
“I believe the printable report could lessen provider burden for insurance payment to obtain the more expensive test that is often necessary to prove patients’ innocence or noncompliance,” Dr. Fudin continued.
The company is also beginning development of another app to help prescribers understand how an individual’s genetics can affect their metabolism of medications, to help improve treatment efficacies, and prevent potential drug interactions. “This information has been available for years,” Dr. Fudin disclosed. “We’re just not using it because of the complexity, lack of training and tools for prescribers to easily select indivualized therapy with a few simple clicks of the mouse.”
Dr. Fudin summarized by adding, “Proper interpretations of UDTs require knowledge of chemistry, pharmacodynamics, pharmacokinetics, therapeutics, and other sciences. UDTapp consolidates this knowledge and uses patient data to generate advice in interpreting UDTs designed for the clinical setting, freeing the practitioner to do what he or she does best; treating their patients.”
 Tennant F. Sudden Unexpected Death in Chronic Pain Patients. Pract Pain Manage. 2012;12(5):37-41.
Also see: http://www.practicalpainmanagement.com/treatments/pharmacological/opioids/opioid-bias-hurts-pain-patients#fieldset