Testing
Do you know all of the medications your patients take?
Some patients have more than one clinician and may not remember all the medications they take. Patients taking legally prescribed controlled medications may be combining prescriptions from multiple prescribers, putting themselves at risk for adverse drug reactions. Those patients who abuse drugs are more likely to combine them with legal drugs you prescribe, putting them at risk for overdoses and adverse reactions.
PtProtect™ pain management panel can help protect your patient’s safety by minimizing the risks of unintended drug interactions. Our interpretive report clearly notes any discrepancies between the medications reported taken and the medications detected.
Identify possible diversion
Patients who use drugs of abuse are more likely to abuse pain medications and more likely to divert medication either for financial gain or to fund an addiction to legal or illegal drugs. Family members may pilfer prescription drugs to self-treat or sell on the street.
PtProtect’s pain management pain will provide you with the documentation needed to address this issue with your patient in a follow-up conversation.
Ensure compliance
Responsibly monitoring patient medication compliance is a challenge. PeaceHealth Laboratories’ pain management panel is designed to monitor patient compliance with commonly used opiates and opioids, as well as to detect common drugs of abuse. PtProtect’s interpretative report gives a holistic view of the medications and substances the patient has taken and provides documentation needed in managing controlled medication prescribed to chronic pain patients.
PtProtect™ Pain Management Panel includes the opiate/opioid panel and a nine drugs of abuse panel. Our testing regimen uses cut-off thresholds that reduce false negative results and confirms screened positives of commonly abused drugs.
Cut-off thresholds
| Pt Protect Pain Management Cut-off /Thresholds | |||||
|
Opiate/Opioid Panel
|
Generic or Brand Name
|
LC/MS-MS Threshold
|
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| Hydrocodone | Vicodin® & others | 5 ng/mL | |||
| Hydromorphone | Dilaudid® | 5 ng/mL | |||
| Oxycodone | Oxycotin®, Tylox®, Percocet® | 5 ng/mL | |||
| Oxymorphone | Numorphan®, Opana® | 5 ng/mL | |||
| Codeine | Tylenol-3® | 5 ng/mL | |||
| Morphine | MS Contin®, Roxanol® | 5 ng/mL | |||
| 6-monoacetylmorphine | Heroin metabolite | 5 ng/mL | |||
| Meperidine | Demerol® | 5 ng/mL | |||
| Fentanyl | Duragesic®, Aetiq® | 2 ng/mL | |||
| Norfentanyl | Fentanyal metabolite | 2 ng/mL | |||
|
Drug Screen
|
Generic or Brand Name
|
Screen / GC-MS Threshold
|
|||
| Alcohol | Ethanol | 0.02 / 0.02 g/dL | |||
| Amphetamine | Methamphetamine | 300 / 150 ng/mL | |||
| Amphetamine | |||||
| MDMA, MDA | |||||
| Barbiturates | Amobarbital | 200 / 200 ng/mL | |||
| Aprobarbital | |||||
| Butarbital | |||||
| Butalbital | |||||
| Pentobarbital | |||||
| Phenobarbital | |||||
| Secobarbital | |||||
| Benzodiazepines | Alprozolam metabolite | 200 / 100 ng/mL | |||
| Chlordiazepoxide metabolite | |||||
| Chlorazepate metabolite | |||||
| Clonazepam metabolite | |||||
| Diazepam metabolite | |||||
| Flunitrazepam metabolite | |||||
| Flurazepam metabolite | |||||
| Lorazepam | |||||
| Nordiazepam | |||||
| Oxazepam | |||||
| Temazepam | |||||
| Cocaine | Cocaine metab | 300 /150 ng/mL | |||
| Marijuana | THC metabolite | 20 /15 ng/mL | |||
| Methadone | Methadone metabolite | 300 / 300 ng/mL | |||
| Phencyclidine | Phencyclidine | 25 /25 ng/mL | |||
| Propoxyphene | Propoxyphene metabolite | 300 /300 ng/mL | |||
Interpretation of results
Promoting pain relief and preventing abuse of pain medications is a critical balancing act for clinicians.
When a clinician receives a result that indicates the patient is taking a medication not prescribed, the patient is questioned about the source of the medications. In some cases, this may result in the patient’s removal from the practice.
For that reason, caution must be used in the interpretation of the opiate/opioids results. Several commonly prescribed opiates (codeine) and opioids (hydrocodone and oxycodone) metabolize to active opiate /opioids drugs which are also available by prescription.
Major Metabolism
In addition to the major metabolism that occurs in standard doses of opiate/opioids, alternative metabolism can occur when high doses of codeine or morphine are used in tolerant patients.
Minor Metabolism
Implications
Determining the source of a detected opiate/opioid can be difficult and requires clinical correlation.
Why would a patient not have a drug present that was prescribed?
- Non-compliance
- Diversion
- Fast metabolizer
- Drug-induced metabolism (e.g. rifampin)
- Poor drug absorption (e.g. celiac disease)
- Diluted urine
Why would a patient have a drug present that was not prescribed?
- Normal opiate/opioid metabolite from a legitimate prescription
- Opiate/opioid metabolite found when high does of codeine or morphone are used
- High dose codeine can metabolize to hydrocodone
- High dose morphine can metabolize to hydromorphone
- Prescription from another physician
- Medication obtained for spouse or friend
- Illicit use of a drug obtained without a prescription
Does the result correlate to a patient’s dosage?
Using urine concentrations to monitor therapeutic levels is unreliable, because
urine drug concentrations cannot determine:
- The amount of drug used
- Establish exactly when the last dose was taken
- Predict the source of the drug
“There is no scientifically validated relationship between the amount of drug taken and urine concentration. Therefore, a urine drug test cannot indicate the amount of drug taken, when the last dose was administered, or the source of the drug” D.L. Gourlay, Y.H. Caplan, H.A. Heit; Urine Drug Testing in Clinical Practice, California Academy of Family Physicians (2006)
Does the test provide a complete morphine evaluation?
Common reasons for the presence of morphine include a morphine prescription, codeine prescription (since codeine metabolizes to morphine), dietary poppy seeds and heroin use.
PtProtect™ Pain Management Panel was designed to address the poppy seed and heroin use. Poppy seeds and morphine drugs, such as heroin, are detected as they are part of the major and minor metabolic pathways for opiates and opioids. For instance, if 6-monoacetylmorphine is detected, it provides definitive proof of heroin use. However, the absence of 6-monacetylmorphine does not rule out heroin use when morphine is present.
Does the Pain Management Panel provide an interpretation for the source of drug metabolites both major and minor?
Several of the opiate/opioid analgesics (codeine, hydrocodone, oxycodone) have major and minor metabolites, which are pharmacologically active (morphine, hydromorphone, oxymorphone respectively) and are available as prescription drugs. Specific ratios of the metabolite to parent drug are utilized to determine whether the presence of these metabolites are actually coming from metabolism of the parent drug, are direct use of the individual drug or a combination of direct use and metabolism. This determination can be difficult, and caution must be used so that a patient is not falsely accused of abuse.
Does PeaceHealth Laboratories have clinical toxicologists available to provide expert interpretation and guidance for physicians and healthcare providers?
PeaceHealth Laboratories has experienced, board-certified clinical toxicologists available to answer questions concerning interpretation of the Pain Management Panel. Due to the complexity of available analgesics and their active metabolites, it is recommended that the complete Pain Management Panel be ordered.
