Poster Number-25 - Patterns of Urine Drug Screen Inconsistency in Patients Referred to Establish Care for Chronic Pain: Why are Many Patients Positive for Buprenorphine?

Patterns of Urine Drug Screen Inconsistency in Patients Referred to Establish Care for Chronic Pain: Why are Many Patients Positive for Buprenorphine?

Purpose:

It is estimated that approximately 1 in 5 U.S. adults had chronic 105 pain in 2019, and approximately 1 in 14 adults experienced “high-impact” chronic pain, defined as 106 having pain most days or every day in the past three months that limited life or work activities (Zelaya, 107 Dahlhamer, Lucas, & Connor, 2020). Pain, especially chronic pain, can impact almost every aspect of a patient’s life, leading to impaired physical functioning, poor mental health, and reduced quality of life, and contributes to substantial morbidity each year (U.S. Department of Health and Human Services, 110 2019b).

Chronic pain has led to a growing opioid abuse problem, with public health officials have called the current opioid epidemic the worst drug crisis in American history, killing approximately 90,000 people in 2021[1]. 

Unfortunately, many patients struggle with self-medication and illicit substance use prior to establishing care with a specialized clinic. This study is a retrospective analysis of chronic pain patients who were evaluated to establish care in a single pain management clinic providing opioid management, interventional pain procedures, and opioid dependence treatment. The clinic accepts most commercial and public insurance providers. To improve this chronic pain and opiate crisis, a first step is to gather basic information describing the characteristics of our patients, investigating patterns of illicit substance use and self-medication within the chronic pain population. These details are particularly important for those where illicit drug use or other activities impede the success in a chronic pain treatment program [2].

 

Methods:

The study design is a retrospective analysis of new chronic pain patients who presented for initial evaluation for care in a single clinic. All patients within the sample had been referred to the clinic from outside clinicians in specialties such as primary care, orthopedics, and other spine specialists. Prior to scheduling an office visit, full chart reviews were performed including physician notes, current pain treatment regimen, and imaging. In addition to evaluation and management, each patient had urine drug screen(UDS) performed via immunoassay at the first visit. From a population of 360 total new patients from June 2021-May 2022, 34 patients were found to have UDS results that were inconsistent with the prescribed regimen[3]. Descriptive statistics were gathered on this population to explore trends that may prompt further investigation.

Results:

Within the data studied, 9.4% of patients were found to have an inconsistent UDS at the initial visit. The most common reason for inconsistency was non-prescribed buprenorphine at 17 of the 34 patients (50%). While buprenorphine had an outsized representation in the sample, other substances were found in the following numbers: 6 patients positive for cocaine (17.6%), 4 patients positive for benzodiazepines (11.8%), 3 patients negative for prescribed medications (8.8%), and 1 patient each tested positive for amphetamines, oxycodone, or gabapentin. Additionally, 1 patient provided a commercial urine substitute in an attempt to subvert accurate testing.

On secondary data analysis, 4 of 17 patients positive for non-prescribed buprenorphine were also found to have concomitant amphetamines. The mean age of patients in the study population was 50.8 years, ranging from 31 to 73 years old. The population consisted of 22 females (64.7%) and 12 males (35.3%).

Conclusion:

The data appears to signify a concerning trend of illicit buprenorphine widely available to patients seeking treatment for chronic pain. Given the nature of buprenorphine manufacturing, much of this illicit medication seems to be diverted from patients with seemingly legitimate prescriptions through other clinics[3]. In particular, cash-only clinics have been shown to increase risk of prescription diversion. Conversely, in previous studies, chronic pain patients who elected into buprenorphine therapy have shown a positive trend toward improvement in pain and quality of life without concern for diversion issues. Given concerning diversion trends in the geographic area surrounding the study center, widespread UDS monitoring via immunoassay and other high-complexity methods may be useful for surrounding clinics to ensure lower levels of diverted medication.

References: Dowell D, et al. CDC Clinical Practice Guideline for Prescribing Opioids–United States, 2022 - draft. Centers for Disease Control. 2022. https://www.regulations.gov/document/CDC-2022-0024-0002
2) Heit HA, Gourlay DL. Urine Drug Testing in Pain Medicine. The Journal of Pain and Symptom Management. 2004; 27(3):260-267.
3) Daniulaityte, Raminta & Falck, Russel & Carlson, Robert. (2011). Illicit Use of Buprenorphine in a Community Sample of Young Adult Non-Medical Users of Pharmaceutical Opioids. Drug and alcohol dependence. 122. 201-7. 10.1016/j.drugalcdep.2011.09.029.
4) Rigg KK, March SJ, Inciardi JA. Prescription Drug Abuse & Diversion: Role of the Pain Clinic. J Drug Issues. 2010;40(3):681-702. doi: 10.1177/002204261004000307. PMID: 21278927; PMCID: PMC3030470.