UDM Solutions

Using Risk Stratification to Determine Testing Frequency for Patients on Long-Term Opioid Rx

One question I’m frequently asked by other clinicians is, “How often should I be testing my chronic pain patients?”

When I ask how they currently determine testing in their practice, the answers range from “I don’t test because I know my patients” to “We roll dice when the patient registers.”

In my experience, physicians as a group have concerns regarding their ability to distinguish low risk patients from those who will likely require frequent monitoring. This concern can lead to a reluctance in prescribing long-term opioid medication.

A smart and frequently used strategy to establish testing frequency is based on stratifying patients based on risk. There are several risk assessment tools available for clinical use. While most clinicians are aware of these tools, there has been little information on how to implement the results (e.g., determine testing frequency). In February 2009, an article funded by the American Pain Society titled Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain recommends using a risk assessment tool along with a History, Physical Exam and other appropriate testing before initiating chronic opioid therapy (COT). According to these guidelines, “Tools that appear to have good content, face, and construct validity include the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1, the revised SOAPP (SOAPP-R), the Opioid Risk Tool (ORT), and the Diagnosis, Intractability, Risk, Efficacy (DIRE) instrument.” Monitoring recommendations for patients at low risk for adverse outcomes is at least once every 3 to 6 months, patients at very high risk could require monitoring on a weekly basis. Those patients falling in between these 2 categories would include those prescribed a change in opioid dosage, patients with an addicting disorder, older adults, those in an occupation demanding mental acuity, patients with an unstable or dysfunctional social environment and those with comorbid psychiatric or medical conditions.

I have personally used the SOAPP-R with good success and have recommended it to others. This 24 question self-report questionnaire is designed to aid in the process of determining which patients are at high risk for opioid misuse. Scores stratify patients into low, moderate and high risk categories. I have recommended UDM intervals as follows:

SOAPP-R Score	Risk Level	Monitoring Frequency
0-9	Low	1-2 times per year
10-21	Moderate	4-6 times per year
22+	High	weekly initially, then every visit

Keep in mind, the patient’s level of risk can change over time. It’s important to perform serial risk assessment surveys to restratify your patients. Also, there are differences between the available tools. You should choose the one that works for your practice.

Risk assessment tools like SOAPP-R are a simple, proven way to evaluate a patient’s potential for misuse. However, these tools should not be relied on exclusively as other monitoring techniques may also indicate high risk (e.g., illicit drugs detected in urine drug testing). For those patients who are high risk, combining UDM with pill counts, frequent follow-up visits, use of prescription monitoring programs (PMP) and family member interviews is an effective and reasonable monitoring strategy.

Prescribing Opioids For Chronic Pain Patients Who Use Marijuana - A Clinical Perspective

A recent reader comment asks the question, "What should be done by a primary physician when a patient intended to be on chronic opiates is using marijuana, especially when repeatedly positive on testing or outright admitting that marijuana use is ongoing?" In an effort to respond, I requested a clinical opinion from my friend and colleague, John Femino, MD, FASAM. John’s response, provided below, outlines his clinical experience with this common scenario. John’s approach aims to involve patients in the therapy process to best understand the reasons behind illicit marijuana usage.

As the reader notes, marijuana use is extremely prevalent in society and the drug has historically been labeled as the most commonly used illicit substance. The current trend of medical marijuana widens the use of the drug in clinical settings across the United States. The reader remarks that marijuana usage is not widely covered in research or educational discussions in the field.

John’s response recognizes both illicit and medical marijuana use as common concerns of clinicians. John provides a usable, practical strategy for prescribing physicians of various medical specialties to treat or refer patients in this scenario, rather than deny them necessary treatment.

“David – The situation is quite analogous to the issue of using/abusing opiates from other sources than the doctor who has been prescribing medication. In Rhode Island, we come across this every day with the advent of the Medical Marijuana Law. Although I feel that the issue of the legality and the proximity of the user to other illicit drugs is a valid concern, it is one that is true for all patients and not just the individual patient on prescribed medication.

I prefer to view this problem as one that’s amenable to a risk benefit analysis – whether the person is getting any benefits from the marijuana use, is experiencing any side effects, or is having other co-morbid problems associated with the chronic pain (e.g., depression, anxiety disorder, sleep, cognitive disturbance, memory problems, or other behavioral issues such as isolation and withdrawal). If the chronic marijuana use is worsening or interfering with the management of the underlying condition, then the risk/benefit profile for ongoing marijuana use would suggest that the treating physician should recommend that the marijuana use be stopped. Since marijuana may be helping the pain control issues, I also suggest that the physician utilize pain scales, pain diaries, and any other patient centered data collection devices that might assist in getting a better “movie” of the impact of the marijuana use on these conditions and complaints. In our experience, when we utilize pain scales to document the effectiveness of marijuana on pain relief, we find that it is very short-lived, paralleling the perceived high and often associated with numerous “side effects”. The experienced marijuana abuser usually experiences the “side effects” as the “desired effect”, whereas the marijuana naïve individual experiences the side effects as an undesired effect, representing for them the “stop signal” rather than the “Ah signal”.

Clearly the most significant benefit of this approach is that it is specific to each individual patient, and demonstrates to the patient that the effect of marijuana is interfering with the medical management and overall course of monitoring prescribed medications and other therapeutic approaches. I emphasize that for most patients in this situation that the side effects will confuse the physician’s interpretation of the patient’s symptoms, possibly exposing them to more medications that could have more significant and potentially dangerous side effects than the marijuana itself. I furthermore point out that most chronic marijuana users are also poly substance users and that adding marijuana to chronic opiates could set them up for relapse back to their drug of choice.

I much prefer a dialogue over the medical risks and benefits than a legalistic approach or one that discharges the patient from appropriate medical care, simply because of their use of illegal substances. On the other hand, we frequently discharge patients for chronic marijuana use because the use represents abuse and dependence and has resulted in more complicated clinical course than if the patient was on alternative medications or non medication treatments.

Documentation in the medical record would include these discussions as well as a quantitative creatinine adjusted cannabinoids level. Often we find that these patients have extremely high levels of marijuana in their system, such that presenting it back to the patient can demonstrate to them that their use may be interfering with other prescribed medications. If the patient listens carefully to your concerns as the primary prescriber, they will make adaptations based upon your suggestions to come up with a better therapeutic alternative. If the patient resist these recommendations and refuses to adapt their marijuana usage despite well-documented negative consequences of the marijuana use, then documentation in the medical record will assist in any medical legal challenges. Documentation of this information into the medical record including a diagnosis of marijuana dependence, can now be presented to the patient and coded on the appropriate billing forms. Most patients get quite concerned when their records reflect that their use is being documented as abuse or dependence rather than their personal preference for a drug that they believe should be legalized. For those primary care physicians who are in this situation, we recommend that an addiction medicine evaluation be performed. Documentation of that consultation in the medical record will also assist in the event of a regulatory review.

For the patient who persists in smoking marijuana despite such documentation and refusal of treatment recommendations, then the primary care physician should consider transfer of that patient to an addiction specialist who can manage their chronic pain and addiction to the marijuana itself. Such patients now have to make a choice that can be an opportunity for them to learn more about their marijuana use as well as reflect upon the importance of their therapeutic relationship with their prescribing physician.

We also like to point out to the patient that their choice of jeopardizing an important therapeutic relationship in their life is indicative of the seriousness of marijuana dependence. Those patients who truly have a terminal condition or one in which their use of marijuana truly has a favorable risk benefit ratio, then the physician can decide that continued use of marijuana is acceptable and will be continue to be monitored closely in the future. In this way any time delay that may be necessary to collect for the data is documented, rather than being viewed by a regulatory agency as “looking the other way”. Our experience with this approach has demonstrated that those patients, who have tried marijuana and found it helpful, may now find with a more careful scrutiny, that other side effects that they had attributed to other medications were really from the marijuana, thereby, assisting them in cooperating with the recommendation to cease marijuana use. For those states that have passed medical marijuana laws, this approach allows an individual basis specific recommendations that are based upon each patients set of symptoms, circumstances, and other environmental situations. It also avoids the endless arguments about legalization by focusing completely on the effect of the drug rather than its legal status.

I hope that this information is useful and I would be glad to participate in any further discussions regarding these topics – John Femino, MD, FASAM.”

John provides a usable strategy for approaching patients being treated in primary care, pain management, addiction medicine and other specialties. There are always, of course, individual case scenarios that will require more or less effort than John suggests. This “hot button” topic of marijuana use will continue to present us with challenges in the clinical setting. Ultimately, as the reader suggests, it’s about treating the “whole” patient. We recognize that there are certainly more viewpoints from a clinical perspective. Please add your opinions and case examples from your experience in the comments.

How Frequently Should I Test My Patients?

As the president of a clinical laboratory, I cannot answer this question for you. There are no published guidelines for urine drug testing frequency from any society, academy or association that I am aware of. As a physician, I can tell you about my experiences, the experiences of my colleagues and published research and recommendations.

I practiced pain medicine in a pain & addiction clinic, so most of my chronic pain patients suffered from the disease of addiction. So as not to appear as being biased (which we were often accused of), we tested every patient at every visit. Our three-strikes-and-you’re-out policy seemed to work well to keep motivated patients in the program, and refer others to a higher level of care. This policy of frequent testing allowed us to address relapse issues early, helped to build trust, and confirmed adherence. All of this improved the care that we delivered to our patients. What I learned through this process is to always give my patients the benefit of the doubt, as long as there’s a UDT collected to corroborate the history.

A colleague of mine uses a popular protocol for testing that stratifies patients based upon risk of misuse or addiction. Patients are placed into low, medium or high risk categories and tested accordingly (i.e., low risk - annually, medium risk - quarterly, high risk - every visit or 1-2 months). This strategy allows for early identification of patients who may be at risk of misuse or addiction and limits potentially unnecessary testing for low risk patients who are making progress in treatment.

Recommendations from research articles and pain medicine publications vary widely in specifics. Of those that recommend testing, some suggest testing every patient at every visit¹, while others suggest testing as a response to aberrant behavior.² There is research that indicates urine drug testing in combination with other clinical observations provide more insight into pharmacotherapy than either used separately.³

Until progress is made in guidelines for monitoring pharmacotherapy, it is up to each clinician to determine an appropriate testing protocol for their practice and their patients. I'd like to hear from you about how you determine testing frequency to monitor pharmacotherapy for your patients and what your experience has been (positive and negative). You can comment on this post or send me an email.

1. Katz NP, Managing Chronic Pain with Opioids in Primary Care. PainEDU.org Inflexxion Health Series, 2007.
2. Hammett-Stabler CA, Webster LR, A Clinical Guide to Urine Drug Testing: Augmenting Pain Management and Enhancing Patient Care. UMDMJ–Center for Continuing and Outreach Education, 2008.
3. Katz NP, et al., Behavioral Monitoring and Urine Toxicology Testing in Patients Receiving Long-Term Opioid Therapy. Anesth Analg 2003;97:1097-102.