AClinicalGuideto UrineDrugTesting - Paindr

1 AU GM EN TI NG pain MANAGEMENT& EN HAN CINGPAT IENT CA REAneducationalactivitydesignedforprimar y carephysicians, familyphysicians, :May2008 ExpirationDate: May31,2009A Cl ini cal Gu ide toUrin e Drug Te st ingSupportedby an educationalgrantfromSponsored byUniversityofMedicine & DentistryofNewJersey CenterforContinuing andOutreach EducationincooperationwithCMEC ertifiedMonographFac ,PhD,DABCC,FACBAs soci ate Pro fessorDep ar tm ent of Pa thology& Laboratory Medi cineUnive rsi ty of No rth CarolinaSchoolof Med ic ineDi rect or of Cl inic al To xicology,Cli nica l Pharmacology,En docri nol ogy , Pe diatricMet abolis m, & SpecialCh emistryMcLe ndonClinical LaboratoriesUNCHos pita lsChap el Hill , ,MD,FACPM,FASAMMe dic al Dire cto rLi fet ree Clinica l Research & Pai n Cli nicPr esi de ntUtah Aca de my of pain MedicineChie f of AnesthesiologyHealthSouthSa lt Lake SurgicalCen terSa lt Lake Cit y, UTEdu ca tion al OverviewUri ne drug te sti ng (UDT)has expa ndedbeyondthe workplaceand no w is uti lize d in a number of con texts.

2 Cli nica lly, UDTisregul arly perf orme d in drug trea tme nt cen ters to mo nitorabsti ne nce fro m illi cit drugsand to co nfirmadh erencetomai nt ena nce drug s, in emergency depa rtme nts to supportbo thacut e trea tme nt de cisi ons and effo rts to prevent futureevents(il li cit drug use is considereda ma rk er for futuretra uma),inpa in cli nics, an d in pri marycare settin gs. Th is mon og raphwil l focus on pati en t-centeredUDTus ed to en han ce th emana gementof chronic pai n patie nts . In th is context,UDTca nse rve as a usefu l tool to help veri fy pa tien t-reportedco mplianceor dem onst rate unr epo rted drug expo su ree key elem en ts of UDTmust be app recia ted to be st utilizeth is tool: the pharmacolog ic cha racte risti cs of the drugstest ed,th eir rel at ionship to the sample,an d th e ana lyses performed byth e labo ra tory.

3 Physi cianswho orde r UDT shouldfrequentlyco ns ult with laboratory scie ntiststo selec t appropriate test s,and keep informed of labo ratorycha nges , such as ad op tion ofnew agent s or assa ys. Ph ysici ans shouldcons ider UD T re sult sin th e co ntex t of all the clinicalinf orma tion , and cont act th elabo ra tory sci ent ist to clarif y te st resultswh en the re is adi screpancy. Unfo rtunately,in a studyam ong fam ily medic inephy sicia ns, only 23% would co ns ult with th e la boratorydirectorwh en confronted wit h an abnormal or un expectedUDT resul e pur pose of thi s mo nog raph is to pro vide th e know ledgenecessary to int erpr et most UDTre sults in the con text of painmana rge t Audi en ceTh is act iv it y is des ign ed for pri mary care , fam il y, and pai nme di ci ne pr ac ti tio ne rs intere st ed in or inv ol ve d wi th the cl inic alma nage ment of pa ti en ts re ce iving opi oid the rapy and theuti li zat ion of UDT in the cli ni cal setting to aid in trea tme arning Objec ti vesAf te r co mp le ti ng thi s educ ati on al ac ti vi ty.

4 Part ic ip ants shoul dbe better able to sti ngui sh betwee n the ne eds of foren sic te sti ng and UD Tus ed in cli ni cal pr act ice . sc ri be th e 2 main typ es of UDT methodo lo gie elo p a st rat egy to inco rpo rat e UDT into pra cti ce andord er appr op ria te tes erpre t UDT re sult s wi thi n the li mit at ion s of curre ntte chn olo gie hod of In stru cti onTo ob ta in CM E cre di t for this act iv ity, pa rti cipa nts are requiredto re ad th e learn in g obj ec tiv es and re vi ew the activ ity in itsen tire ty . Regis ter onl in e atht tp:// cco dnj. ed u/ onli ne/ac tiv iti es/ 09MC 07an d co mpl ete the post- te st cons is ting of aseri es of mul ti pl e-ch oice que sti ons . Upo n achi evinga pass ingsco re of 70% or more on th e pos t-t es t, and succ es sf ull yco mp le tin g the eva lua tio n, pa rt ici pa nts ca n immediat ely pri nt aCM E cre di t letter.

5 No addi tiona l cred it le tte rs wi ll be mai le rt ic ip an ts may ta ke the act ivity as many tim es as nec essary toful fil l the req uire me nts .Acc re dit ati onUMD NJ C ent er for Con tinuin g and Out re ach Ed uca tio n isacc red it ed by the Acc red it at ion Co un ci l for Continuing Med ic alEduc at ion to pro vide co ntinui ng educa tion for phy si cia NJ C ent er for Con tinuin g and Out re ach Ed uca tio nde sign ate s this ed uc ationa l act iv it y for a maxi mum of APRA Category 1 Cr ed it(s)TM. Phys icians should only clai m cre di tco mm ens ur at e wi th th e exte nt of thei r part ic ipationin theac tiv ity .Th is act iv it y was pe er -re view ed for re leva nce , accur acy ofco nt ent , and bala nc e of pre se nta ti on by Iris G.

6 Udasi n, MD ; andpi lo t-t es ted for tim e re qui red fo r part ici pa ti on by Ste phe nLe mk e, DO, Kinshasa Mort on, MD, and Ada m L. Pal anc e, Aca de micAdv isorIri s G. Uda sin , MDCli ni cal Ass oci ate Pro fes sor of Env iro nm ent al &Occup at ion al Medi cin eUMD NJ R obe rt Wo od John son Me di ca l Sch oo lPi scataw ay , NJCopyright 2008 UMDNJ Centerfor Continuingand rightsreservedincludingtranslationinto part of this publicationmaybe reproducedor transmittedin any formor by any means,electronicor mechanical,includingphotocopying,recordi ng,or any informationstorageand retrievalsystems,withoutpermissionin writingfrom UMDNJ Centerfor Continuingand ult y Disclo sure Decla rationsDr. Hammett-Sta blerhas no relev ant fin an cial rela tion shi Websterhas recei ved gran t/rese arch supportfrom Ab bottLabo ra tor ies, Ame ri tox , Arrya, As traZe neca,Bo eh ring erIng elheim,CoMentis, DURECT, Fores t La boratories,Glax oS mithKlin e, Jazz Pha rmac eut icals , Merc k & Co,Neur ogesX,Orthocon,Predi x Pha rmac euti cals, PainTh er ap eutics,QRx Phar ma , Res piron ics, TakedaPh ar maceuticals, TorreyPines The rap eutics, Wye th, andZA RS Ph ar ma; has been a con sulta nt for an d has receivedgra nt/research su pportfrom Ad va nc ed Bion ics, AlpharmaPh ar maceuticals, Ela n, Elite Ph arm ace uticals, Ki ngPh ar maceuticals, Medtronic, an d Nekta r Therapeutics.

7 Hasbeen a con su ltan t for Ceph alon , Cov idie n, an d Nervo; andha s servedon the ad viso ry boa rd of an d has receivedgra nt/research su pportfrom PurduePh arm e CMEacademic adv is or, Iris G. Udasi n, MD, an d pilo t-te ste rs Stephe n Lemke,DO, Ki ns has a Morton, MD, andAd am L. Pal an ce, MD , have no relev an t fi nan cialrela tio nsh nni ng com mi tte e members, Jam es Barrett and AngelaCase y, Ph arm aC om Group, and Pa tric k Dwyer , UMDNJ,ha ve no relevant fi na ncia l relati ons hips .Disc laimerTh e view s ex pre ssed in th is act iv it y are th ose of the sho uld not be inferredor as sumedtha t th ey are ex pres singth e viewsof Alpharma, Inc., any oth er manufacturerofph ar maceuticals or test ing de vi ce s, UM DNJ, or Pharm aComGro up.

8 The dru g se lecti on and do sag e in form atio n provi dedin th is pu bli cat io n are believedto be ac curate. Ho weve r, theread er is urge d to cons ult th e full pre scribing in formation onan y dru g me nt ion ed in thi s pub licat ion for recommendeddosa ge, indication s, co nt rain dica tion s, warn ings,prec autions, an d adv erse effect s befo re prescribing anymed ica tion. This is particularlyim porta nt whe n a drug isne w or infrequent ly pre f-La bel Us ag e DisclosureThis acti vity doe s not conta in in formation aboutco mme rcial pro duc ts/d ev ic es tha t are unla beledforuse or in vesti gat io nal us es of products not yet en tsIntrodu cti on .. 2 Opi oi d Th era py in Pa in Man age ment.

9 2 Sco peof Dru use/ Misu seinChr on icPa inPa tie nts ..3 Patien tRi skof Disp la yin gAD RBs ..3Pa tie nt Se lf -R epo rti ng .. 4Sc re enin g Ins trume nt s .. 4Ut ilizing Uri ne Dr ug Te sti ng in Clinic al Practice .. 5 Cli ni ca lVer sus Forens ic/ Wo rk pla inMan age ment ..5 Tre atm en t Ag ree me nt s.. 5 Ong oi ng Moni to rin g .. 6Ad dre ssingUDTRe sults ..6 Und erut ili ze dUD T ..6Ur ine Dr ug Te st ing Met hodologi es.. 7Im mu noa ss ayScre eni ora to ry- Ba sedSpe ci ficDru gIdentifica tio er Con firm at or y Testing .. 8 Rep ort ingof Re sult s ..8Te stin gMen u ..8 Cus tomiz ing a Pai n Mana gem ent Pr ofile.. 9Po int- of -Car eTe stin g ..9Ev al ua ti ng POC T .. 10 Spe ci me nTampe ri ng/Vali dity ..10In Viv o Ad ul tera tion.

10 10In Vitro Adul ter ation .. 10 Uri ne Sub stitu tion .. 11 Val id it y Testi ng .. 11 Col le ct in g the Sa mpl e.. 12In ter pr et at ion of Urine Drug Tes ting Results.. 12 Fals e-N eg at ive Re su lt e-P osi tive Re su lt abo li sm ..14Ph arma coge netic Tes tin g .. 14 Dru g-Cla ss- Spe ci fic Wi ndo wsof Dete ctio vea tstoInte rpr eta tio n ..15 Pre di ct in g Dose Com pl ian ce .. 15 Con sulta tio nWi thLab ora to ry Sci ent ists ..15 Eme rgi ng Te chn ol ogi es for Dr ug Te st ing .. 16 Alte rn ative Speci men oo d/Se rum /Pla sma .. 16 Ora l Fluid .. 16Ha ir .. 17Sw ea t .. 17 Alt ern ativ e Spe ci men s Summ ary .. 18Te stin gfo rAlco hol Abs tinen ce ..18Pr act ice Man age ment .. 19Se le ct ingaTe sting La bo ra to ry: Que stions to Ask.