Pain Treatment Technology Update: An App for Improving Interpretation of Urine Drug Testing

Pain Treatment Technology Update: An App for Improving Interpretation of Urine Drug Testing

NATIONAL ASSOCIATION OF BOARDS OF PHARMACY

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:

kurt1

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.

UDTkurt2aapp 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.”

Notes:

[1] 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

Authored by: Kurt W.G. Matthies

There are 10 comments for this article
  1. https://shampooforcurlyhair.wordpress.com/ at 5:26 pm

    I’m impressed, I must say. Rarely do I encounter a blog that’s equally
    educative and amusing, and without a doubt, you have hit the nail on the head.

    The problem is something that not enough folks are speaking intelligently about.

    I’m very happy that I came across this during my search for something relating to this.

  2. Zyp Czyk at 11:43 am

    Unlike other Americans, we are presumed guilty until proven innocent.

  3. Payne Hertz at 10:59 am

    Drug-testing is another money-making scam by which doctors enrich themselves at our expense.

    Drug testing
    1. Is prone to major errors.
    2. Is administered with no standards or oversight.
    3. By people who don’t have a clue how to interpret the results
    4 .Are expensive
    5. Invite fraud and abuse.

    We need this why?

    This article points out some of the harms associated with false positives, but fails to mention that the harms caused by true positives are identical and just as destructive.

    Whether you have a false positive or a real positive, the usual result is a non-judicial sentence of torture administered by a doctor on the spot with little chance you will ever get a pardon and no chance of challenging your sentence in a court of law. We are expected to adhere to a standard of puritanical perfection with any failure to comply subject to arbitrary and cruel punishment.

    Is this just? Of course not. It is interesting few doctors have a problem with the injustice here until you suggest they should be getting tested as well, then the wailing and gnashing of teeth begins:

    http://www.kevinmd.com/blog/2010/08/physicians-undergo-random-drug-testing.html

    How comfortable would Dr Fudin be if he faced getting summarily fired and barred from medicine for life based on a drug-test interpreted with his software?

    We should be organizing to fight this crap tooth and nail not celebrating every “improvement” in the tools used to oppress us.

  4. Oscar Linares at 1:29 pm

    Dr. Fudin is to be commended for taking a “major” forward and upward step to help both prescribers and patients. I applaud his efforts.

  5. Oscar Linares at 1:23 pm

    This is very good. However, you missed an important paper that integrates pharmacogenetics with UDT.

    A new model for using quantitative urine testing as a diagnostic tool for oxycodone treatment and compliance.
    Linares OA, Daly D, Stefanovski D, Boston RC.
    J Pain Palliat Care Pharmacother. 2013 Aug;27(3):244-54.
    PMID: 23879213

  6. Doc Anonymous at 8:01 am

    And to make matters worse, some of the docs who perform UDTs in their offices are now being raided for “overbilling” insurance for doing too many UDTs! And did you know that insurance company investigators (with a vested interest in insurance company dollars…NOT patient well being) are by law working right along side the police agencies?

    It seems that legitimate pain treatment has become the carcass on which the carrion crows are feeding! I leave it to you to name your crow.

  7. Kristina Schwende at 4:14 am

    While it’s good that this app will help “prove” that patients are telling the truth in spite of questionable results, what about the deeper issue – Chronic pain patients are being put at significant risk. Imagine if you lived with debilitating pain and you suddenly lost access to your medications and your doctor. Not only would that be terrifying, but what options would you be left with? For many people, it comes down to illegal drugs or suicide. I am not exaggerating. I have been in so much pain that I wanted to die (I would be dead were it not for my faith). I have gone to the ER in blinding pain, and the moment they look at my chart and see the pain meds I’m on, they refuse to help me. If that weren’t bad enough, it’s the attitudes that come with it – disdain and suspicion. Surely this deplorable treatment is unconstitutional or at the very least unethical!
    If a doctor truly suspects that someone is abusing their meds, have them properly assessed at a treatment facility. Then, once they are cleared, hopefully the doctor/patient relationship can be restored. For those who are diagnosed with a drug problem, give them the help they need instead of abandoning them! If a doctor choses to abandon their patient (which is basically having them blacklisted within the medical community), they should be held accountable for their negligence. Even if the issue stems from legislation, that shouldn’t give doctors free reign to abuse their patients. Make no mistake – this is abuse (see definition http://en.m.wikipedia.org/wiki/Psychological_abuse). How on earth can that be OK?

  8. Mark Ibsen at 9:46 am

    But industry experts say the soaring cost of drug screens is not just a reflection of the increasing use of narcotic painkillers. It’s also caused by unnecessary testing, overbilling and outright fraud by doctors and drug screening companies.

    “They’re billing for too many drugs. They’re doing it too often and in many cases they’re getting results that don’t mean anything,” one industry source told American News Report.

    The CWCI study found that between 2004 and 2011, the average amount billed per drug test rose from $81 to $207 (+156%).

    The number of drug screens in the study also soared, from 4,012 tests in 2004 to 186,023 tests in 2011 (+4,537%).

  9. Mark Ibsen at 9:41 am

    What a complicated mess. It would’ve been great if the Federation for state medical board’s would have done the actual research on urine drug testing:
    Millions of dollars are being spent on a process that actually just confuses the treatment for the patient. There is no evidence that urine drug testing aids in patient care, prevents dive version, or does anything but confuse the entire issue.
    Dr. Fudin proposes a great service to those patients who are being abandoned irrationally, without adequate evidence. Another term for irrational behaviors, executed in haste, without evidence: witchhunt!

    I propose a cheaper, simpler app:
    Unmitigate!

    Since there is no evidence to support the use of urine drug testing in pain patients specifically, the simpler easier and cheaper method would be to NOT PERFORM it.

    This app will be called:
    JustsaynoAPP.

    Mischief Managed.