Recent research shows that random urine toxicology screenings are essential to monitor patients’ adherence to pain medications accurately and assess drug-taking behavior. A study of 32 patients taking pain medication at a New York City pain clinic between December 2007 and March 2008 showed that 56% had taken their prescribed medications, whereas 44% had toxicology results inconsistent with the medications they had been prescribed.
Study Investigator Mauricia P. Alo, RN, MSN, NP-C, nurse practitioner at the NYU Langone Medical Center Hospital for Joint Disease Comprehensive Pain Treatment Center, says inconsistent results were classified further as those containing illicit substances, such as marijuana or cocaine; another opioid that had not been prescribed; or another controlled substance, such as amphetamines. Inconsistent also could mean that there was an absence of the prescribed medication because the patient wasn’t taking it.
“Our results were comparable to a 2007 study done by Michna et al [published in the February 2007 issue of The Clinical Journal of Pain], which also was based on random urine screenings in a teaching hospital pain management program, where they found 45% of 470 patients they tested had results inconsistent with the drug(s) they were prescribed,” Alo says.
Alo explains that when random screening tests revealed that patients were taking illegal drugs, they were counseled.If they had taken illegal drugs before, they were discharged from the pain management program and given referrals for counseling. Patients whose urine was negative for any drugs and who said they were taking their medications as instructed were told that they would no longer be provided opioid medications. One of those patients preferred to seek pain management elsewhere rather than be prescribed non-opioids. The Federation of State Medical Boards recommends that practices screen for patient compliance to prescribed drug regimens to limit abuse or misuse. At the center, patients undergo an initial screening before starting treatment. Those who want to begin pain management and are discovered to be taking nonprescribed narcotics or illegal drugs may be able to enter the hospital’s 10-day rehabilitation program. A multidisciplinary team comprised of the physician who oversees the program, a psychiatrist, a psychologist, an occupational therapist, a physical therapist, a rehabilitation therapist, a social worker, and an advanced practice nurse evaluates such patients to determine their appropriateness for the program.
Agreement Spells Out The RulesNurse practitioner Mauricia Alo reported on her study at the 12th Annual Nursing Research Evidence-Based Practice Conference last June, which was sponsored by NYU Langone Medical Center.
The random drug screenings are ongoing at the center and are a routine part of the pain management agreement that all patients sign. As long as they are taking opioids, the center’s patients are subject to the screenings and any other responsibilities outlined in the agreement, which also outlines the physician/nurse responsibilities related to the administration of controlled narcotics for pain. The 14-point agreement says that patients must promise to talk with the physician or NP about their pain and how the medication is controlling it; promise not to share, sell, or trade their medications with anyone; inform the physician and nurse of medications prescribed for other conditions; and promise not to obtain any controlled medicines from other healthcare providers. “Adherence to the agreement should be emphasized often, and violation of it should be grounds for discharge from the practice,” Alo says.
Although this study is limited, Alo says it confirmed the value of doing initial urine drug screenings on patients under consideration for opioid treatment and then randomly doing them during follow-up visits. “The increasing abuse of prescription drugs should concern every practitioner who prescribes opioids,” Alo says. “Physicians and other providers who prescribe controlled substances should remember that they assume responsibility every time they prescribe a drug with abuse potential, including the social responsibility to uphold the law and help protect society from drug abuse.”
This also includes the professional responsibility to prescribe controlled drugs appropriately, guarding against abuse while assuring that patients have medication available when they need it; a personal responsibility to protect their practices from becoming easy targets for drug diversion, which could result in disciplinary action and possible loss of the license to practice medicine; and a legal responsibility to learn the relevant requirements of state and federal law that govern the prescription and use of controlled drugs.