Editor’s Note: Terri Lewis is a frequent contributor to editorial content for the National Pain Report. She is a patient advocate and educator and a parent and daughter of persons with chronic pain. She is a PhD in Rehab counseling and currently teaches rehabilitation counseling to allied health clinicians, physicians, and counselors in Taiwan.
I have an observation and a suggestion regarding recent dialogue about urine drug testing.
Patient selection is an extremely important part of treating the patient with chronic, long term or intractable pain. Patient selection doesn’t stop with the question of whether or not one wants to treat the person in front of you or whether or not you are the right clinician. Patient selection includes selection of treatment protocol based on the characteristics of the consumer. The characteristics of the consumer are not dictated simply by the diagnostic label, the demographics, the payor sources, or their degree of pain – they are determined by whether or not one has a history of increasing pain or disease, impairment, disability and handicap. If indeed they have processed from simple impairment to disability and handicap without benefits derived from treatment, there is a REASON FOR THIS. That reason is often associated with the ability of the clinician to theorize a treatment intervention based on their understanding of the patient, the disease process in question, and the likelihood of benefit. Too often the clinician conceptualizes these patients from an acute treatment model, even in the face of advanced disease.
With chronic pain, we are tempted to undertreat or overtreat based on assumptions and biases. Too often we fail to determine whether the patient is likely to benefit from the treatment protocol we have the most experience with. There is a reason why people do not respond properly to some oral medications and that is because they cannot metabolize them due to genetic predispositions in the CYP groups of liver enzymes. After observing the pain histories of literally hundreds of patients I have to wonder why we fail to employ this simple test BEFORE we issue prescriptions for opioids, ssris, anti-epileptics, etc.?
The UDT assumes that all patients metabolize similarly and unless one uses HPLC at the beginning, one will never know what in fact the urine drug screen has truly measured. It is only when we have a better understanding of which patients are likely to benefit from certain classes of oral medications that we can then use the UDT properly to make determinations that supplement treatment decisions. Or, when we know that the available classes of medications are not likely to be effective, we can save ourselves from applying the dangerous fail first approach that requires tx without results or may create significant conditions of harm. Too many consumers are forced into fail first treatment applications which are far more expensive over the long haul than utilizing the CYP450 clinical test application.
I have personally observed far too many consumers who are dumped as the result of improper patient selection that uses the UDT to confirm lack of or errant results. In my experience, the use of a pain contract, coupled with an uninformed clinician who uses the UDT to discharge a patient, is a dangerous and sometimes life threatening combination – for the patient. It puts them on a course of continued treatment error and may force them into the use of other people’s medications in order to get relief.
One also has to consider the ethics of pain contracts and UDTs – is the patient operating at egregious levels of pain truly capable of giving ‘consent’ when the clinician withholds treatment until an agreement can be extracted, and without conducting the appropriate examination and clinical assessment to assure that ‘fail first’ is unlikely?
The CYP450 is far underutilized in my opinion. We need to know much more about this because it tells us a lot of disease mechanisms in the glial cell activation system. And that is important for understanding the nature of pain and disease processes.
Have you taken the Patient Survey on the National Pain Strategy issues that Dr. Lewis is conducting? She will share the results with the National Pain Report.
To take the survey (click here)
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