Pain management centers face challenges in delivering consistent, effective care to patients who each have unique interpretations of symptoms. Barriers involved in pain management include poor communication, drug diversion and non-compliance. Drug testing is a proven way to achieve expected outcomes in every stage of pain management, from patient assessment to risk mitigation.
Drug Testing for Patient Evaluation
Beginning with the first visit to a pain management center, patients can expect to have a thorough physical carried out by their provider. Open communication is crucial for doctors to learn the source of a patient’s symptoms, whether it be through drugs of abuse, an underlying health condition, or a combination.
Urinalysis exams can identify hormonal and metabolic abnormalities, but are often adopted in pain management clinics to reliably assess current drug abuse. Drug testing throughout the course of patient care helps providers hypothesize the cause of pain symptoms. Drug testing also eliminates the need for flawed patient self-reporting.
Drug Testing to Achieve Expected Outcomes
A hurdle in delivering effective pain care is outlining parameters for expected results. This can be problematic if providers wish to design individual versus fixed treatment templates. Drug diversion, which is the distribution of pharmaceuticals to anyone aside from the intended patient, is grounds for discharge.
One size does not fit all, but drug testing can measure each patient’s compliance rate. Obtaining proof of compliance is achievable through integrated drug test panels which pinpoint the presence of prescribed drugs. Drug testing ensures patients and providers are on the same page.
Drug Testing Within Risk Evaluation and Mitigation Strategies (REMS)
Drug testing is a useful component of REMS, a system recommended by the FDA to be implemented in pain management settings. Risk mitigation is important when dealing with patients who have an inclination towards drug abuse. Addiction throughout the course of treatment must be quickly identified so physicians do not misplace their time.
Polypharmacy defines the concurrent use of multiple medications to alleviate pain symptoms of the same ailment. Though necessary in special circumstances, polypharmacy can increase the risk of drug addiction in patients with access to prescriptions from multiple sources e.g. their primary doctor, pain management physician, etc. Pain management providers must be cautious of the interactions between different prescription medications. Urine drug testing determines the presence of several drug metabolites in one, all-inclusive format.
Treating pain can be a trial and error process. Using drug testing to develop evidence-based hypotheses, observations and conclusions sets precedence in care.
Pain Clinic Services
At pain clinics, therapy plans are tailored to each patient’s specific needs and preferences. Treatments may include any combination of the following depending on the cause of pain:
- Pain Medications – Patients are often prescribed medication before receiving any other form of therapy. Common pain meds can include:
- Non-aspirin pain relievers – to relieve minor pain, these drugs are sometimes combined with other drugs for greater pain relief. Examples – Tylenol, Calpol (acetaminophen)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) – to treat pain AND inflammation, these drugs are available either OTC or by prescription. Examples – Motrin, Advil (ibuprofen)/ Aleve, Naprosyn (ornaproxen)
- Corticosteroids – these are prescription-only drugs used for more severe inflammatory conditions.
- Opioids – these are morphine-like drugs usually prescribed for short-term acute pain or cancer pain. They may also be prescribed for chronic non-cancer pain.
- Anti-depressants – originally intended for treating depression, these drugs can help relieve certain types of pain and promote sleep, which is often difficult while a patient is in pain.
- Local anesthetics – Sometimes patients may be injected with local anesthetics into muscles, joints and around nerve roots (nerve blockers) to relieve muscle spasm, swelling and irritation.
- Physical & Aquatic Therapy – A doctor who specializes in physical medicine and medicine rehabilitation is called a physiatrist. It is a physiatrist and/or a physical therapist who would normally develop special exercise programs tailored to a particular patient’s needs in order to relieve pain while increasing function in specific areas of the body. Pain clinics offer other physical therapy options like deep muscle massage, ultrasound therapy and whirlpool therapy.
- Acupuncture – An ancient Chinese practice of relieving pain by inserting very thin needles at very specific points on the skin.
- Electrical stimulation – A technique to manage pain by stimulating nerve fibers on the skin, the most common of which is TENS (transcutaneous electrical nerve stimulation).
- Heat application – A technique to relieve pain by applying heated pads to specific areas
- Counseling and Psychological Support – Many people suffering from chronic pain also suffer from feelings of anger, frustration, sadness and hopelessness. Constant pain makes it hard for sufferers to hold down a job, run a home and meet familial and social obligations. Psychological support is often part of the holistic approach to pain management.
- Relaxation therapy – On top of counseling, there are many relaxation and self-help techniques that mental health professionals can teach patients to help relieve stress and manage pain, including Biofeedback.
- Surgery – Surgery is sometimes necessary to correct a physical problem that causes pain, but it is often regarded as a last resort – only considered when a patient does not respond favorably to other treatment.
- Aromatherapy – According to more recent modern studies, inhaling or absorbing aromatic plant extracts may help relieve pain by soothing the body, but aromatherapy itself has roots in ancient civilizations like China and Egypt.
Apart from the actual pain treatment services, pain management facilities also handle the following:
- Out-patient pain medication, including those for the elderly.
- Prescribing opiates
- Drug monitoring
- Pain Psychology
- Opiate addiction resource management
- Interventional pain medicine (surgeries and other out-patient procedures)
Drug Testing in Pain Management
Why should pain management clinics routinely perform drug monitoring? Prescription pain relievers play a major role in the management of chronic pain and are therefore made easily accessible to the hundreds of thousands of people suffering from various forms of this ailment. There has to be a way for pain management professionals to assess a patient’s adherence or compliance to the pain treatment plan. This is done thru drug testing or more specifically these days, point-of-care testing.
A most popular tool is a urine drug test (UDT). Test results can provide objective information that can help in the diagnosis and subsequent decisions about appropriate therapy. The presence of prescribed pain medication is evidence of their use. Some positive results may indicate levels much higher than expected. A negative result or the absence of such drugs can indicate that a patient may have been over-medicating and therefore ran out of meds way before the scheduled sample collection. Sometimes a point-of-care test may find unprescribed or illicit drugs in the urine. Any of these results will merit further discussion with the patient. By doing drug monitoring routinely, the pain management team can make a better diagnosis and catch a relapse or drug misuse early on. Sometimes drug test results may indicate addiction or pseudo-addiction or chemical coping (the use of other opioids not intended for pain relief).
The purpose of a urine drug test should be explained to the patient from the very beginning, during the evaluation process. The treatment plan should be mutually agreed upon by the health care team and the patient. Often within the context of pain management, a UDT result that shows the presence of unprescribed drugs does not necessarily invalidate a patient’s pain issues. It only suggests a concurrent disorder like substance abuse or addiction. The patient must be made to understand that assessment and treatment should include all relevant and concurrent disorders in order to reasonably expect positive outcomes. Again, drug monitoring is vital in this process.
Drug Test Methods
Urine testing is the method most technologically developed and is therefore the most widely preferred for detecting the presence or absence of most substances, prescribed or otherwise. Additionally, most drugs and their metabolites have a long window of detection in urine (see Table 1 below for approximate drug detection times).
Many urine drug test cups and urine drug test dip cards are ideal for use as point-of-care tests at pain management clinics. These test kits provide accurate results right when needed for evaluating a pain patient’s particular treatment needs and monitoring adherence to the pain treatment plan. For routine urine drug tests, a standard panel should test for Amphetamines/Methamphetamine, Benzodiazepines, Cocaine, Marijuana, Methadone and Opioids.
Saliva testing has steadily climbed in popularity over the last decade owing to its affordability and ease of use. Many saliva drug tests are readily available from drugstores, pharmacies and many online suppliers. They are ideal for use as point-of-care test kits in a pain management setting because they provide quick and accurate results.
Hair drug testing is another drug test method that is ideal for monitoring adherence to pain medication regimens. A standard 1.5-inch sample will show a 90-day drug use profile for a patient. While it is more expensive than urine or saliva testing, it also needs to be done less frequently.
TABLE 1: Approximate Drug Detection Times
|Amphetamine||2-4 days||1-3 days||7-90 days|
|Methamphetamine||3-5 days||1-3 days||7-90 days|
|Cocaine||2-4 days||1-3 days||7-90 days|
|THC||15-30 days||6-12 hours||7-90 days|
|Opiates||2-4 days||1-3 days||7-90 days|
|Morphine||2-4 days||7-90 days|
|PCP||7-14 days||1-3 days||7-90 days|
|Ecstasy (MDMA)||1-3 days|
|Tricyclic Antidepressants||7-10 days|
The drug detection times shown are approximate values and must be interpreted depending on several factors like the variability of the samples, drug metabolism and half-life, the patient’s physical condition at the time the samples were taken like his/her food and fluid intake, and the method and frequency of ingestion.
Drug Use Statistics in Pain Management
- Over 30% of Americans suffer from some form of acute or chronic pain.
- In 2014, retail pharmacies in the U.S. dispensed a total of 245 million prescriptions for opioid pain medications, of which 65% were meant for short-term pain therapy (less than 3 weeks).
- Approximately 7-10% of drug diversion involves patients who fake their pain problems to acquire prescribed opioids. These same patients will often go doctor shopping, or go to multiple physicians to attempt acquiring multiple prescriptions.
- An estimated 4% of people addicted to prescriptions opioids for their pain issues eventually transition to heroin because it is cheaper.
- According to the NIDA , the most commonly abused prescription drugs are opioids, CNS depressants and stimulants.
With prescription drug abuse consistently on the rise, the pain management industry faces an equally increasing pressure to pay a closer attention to their drug monitoring/drug testing processes as a critical component of the whole pain management regimen for each of their patients.