Role of urine toxicology testing in the management of chronic opioid therapy

Determination of 465 psychoactive substances, drugs and their metabolites in urine by LC-MS/MS

Due to the emergence of novel psychoactive substances on the drug market, there is a growing demand for analytical methods allowing identification and determination of as many psychoactive substances as possible in the shortest possible time, which can be easily expanded to include additional analytes appearing in street trade. Immunochemical methods are not sufficient to meet constantly growing requirements. Therefore, the aim of the study was to develop an analytical method enabling quick analysis of urine samples for psychoactive substances, drugs and their metabolites. Liquid-liquid extraction (LLE) and liquid chromatography coupled with mass spectrometry (LC-MS/MS) were used for this purpose. Using available analytical standards, the operating parameters of the mass spectrometer were selected for each of the 477 analytes, and MRM (multiple reaction monitoring) acquisition was selected for each of them. The use of analytical standards allowed for the identification of analytes separated on the chromatography column. The exceptions are methylmethcathinone isomers (3-MMC and 4-MMC), which we were unable to separate using the gradient elution method used. Extraction using acetonitrile with the addition of ammonium formate and formic acid allowed us to obtain high recoveries without the use of β-glucuronidase. Recovery values ranged from 18.43 to 119.94%. The matrix effect was eliminated by obtaining a calibration curve in the matrix. The developed analytical method was validated in accordance with SWGTOX guidelines. Only 12 substances did not meet the validation criteria (CV: ±20% and bias: ±20%). Thus the validated method makes it possible to determine 465 psychoactive substances in just 30 minutes. In the validation process, values such as the limit of detection (LOD) and the limit of quantification (LOQ) were also determined. The LODs are in the range of 3-30 ng mL-1, and the LOQs are in the range of 10-100 ng mL-1. The method was successfully applied to toxicological analyses of urine samples, which was an opportunity to develop it further to meet the needs of toxicology.

Digital Biomarker Applications Across the Spectrum of Opioid Use Disorder

Opioid use disorder (OUD) is one of the most pressing public health problems of the past decade, with over eighty thousand overdose related deaths in 2021 alone. Digital technologies to measure and respond to disease states encompass both on- and off-body sensors. Such devices can be used to detect and monitor end-user physiologic or behavioral measurements (i.e. digital biomarkers) that correlate with events of interest, health, or pathology. Recent work has demonstrated the potential of digital biomarkers to be used as a tools in the prevention, risk mitigation, and treatment of opioid use disorder (OUD). Multiple physiologic adaptations occur over the course of opioid use, and represent potential targets for digital biomarker based monitoring strategies. This review explores the current evidence (and potential) for digital biomarkers monitoring across the spectrum of opioid use. Technologies to detect opioid administration, withdrawal, hyperalgesia and overdose will be reviewed. Driven by empirically derived algorithms, these technologies have important implications for supporting the safe prescribing of opioids, reducing harm in active opioid users, and supporting those in recovery from OUD.

Assessing risk for nonmedical opioid use among patients with cancer: Stability of the CAGE-AID questionnaire across clinical care settings

OBJECTIVES

The Cut down, Annoyed, Guilty, and Eye opener- Adapted to Include Drugs (CAGE-AID) questionnaire (CA) is a validated screening tool used to assess risk for nonmedical opioid use (NMOU) in patients receiving opioids for cancer pain. Data on consistencies and variations in responses to the CA between different clinical settings are lacking. We evaluated the frequency and consistency in scoring of the CA among patients seen between the first inpatient consult (T1) and the first outpatient follow-up (T2) visits.

METHODS

A retrospective chart review of 333 consecutive patients seen at both T1 and T2 within 3 months between August 2016 and March 2017 was reviewed.

RESULTS

Median age was 58 years (range, 18-87 years); 53% were female. CA was completed for 88% of patients at T1 and 94% at T2. Of these, 10% and 13% were CAGE-AID positive, respectively. CA score changed from negative to positive in 4% and from positive to negative in 1% of patients between T1 and T2. Kappa coefficient for agreement of CA between T1 and T2 was 0.74 (95% CI: 0.62-0.86, p = 0.02).

SIGNIFICANT OF RESULTS

Completion rate and consistency of patient responses to the CA were high irrespective of clinical setting. Of these patients, 10% and 13% were CA positive which is suggestive of high risk for NMOU. Further studies are needed to evaluate ways to ensure more consistency in the completion of the CA and enhance its utilization in routine clinical practice.

A High-Throughput Ion Mobility Spectrometry-Mass Spectrometry Screening Method for Opioid Profiling

In 2017, the United States Department of Health and Human Services declared the widespread misuse and abuse of prescription and illicit opioids an epidemic. However, this epidemic dates back to the 1990s when opioids were extensively prescribed for pain management. Currently, opioids are still recommended for pain management, and given their abuse potential, rapid screening is imperative for patient treatment. Of particular importance is assessing pain management patient compliance, where evaluating drug use is crucial for preventing opioid abuse and potential overdoses. In this work, we utilized drift tube ion mobility spectrometry coupled with mass spectrometry (DTIMS-MS) to develop a rapid screening method for 33 target opioids and opioid urinary metabolites. Collision cross section values were determined for all target molecules using a flow-injection DTIMS-MS method, and clear differentiation of 27 out of the 33 opioids without prior chromatographic separation was observed when utilizing a high resolution demultiplexing screening approach. An automated solid phase extraction (SPE) platform was then coupled to DTIMS-MS for 10 s sample-to-sample analyses. This SPE-IMS-MS approach enabled the rapid screening of urine samples for opioids and presents a major improvement in sample throughput compared to traditional chromatographic analyses coupled with MS, which routinely take several minutes per sample. Overall, this vast reduction in analysis time facilitates a faster turn-around for patient samples, providing great benefits to clinical applications.

Evidence based opioid weaning with behavioral support - Forum for Behavioral Science Edition

Nationally published guidelines state that many patients prescribed chronic opioids would benefit from gradually reducing and/or eliminating their use of these medications. This is easier said than done. Patients are often resistant or fearful, physicians are often uncomfortable prescribing an opioid taper, and patients often do not get the needed behavioral health support in this process. It is critical to develop a comprehensive behavioral and medical plan, however the field lacks practical approaches to guide physicians (and patients) through this challenge. In this manuscript our team of primary care providers and behaviorists walk through a case involving complex opioid weaning in a Family Medicine residency clinic environment. Through the lens of our patient's case, we will discuss best practices for getting patient buy-in, opioid weaning strategies, behavioral support during the wean, identifying co-morbid opioid use disorders, and deciding on acceptable end points for the taper.

OpiTrack: A Wearable-based Clinical Opioid Use Tracker with Temporal Convolutional Attention Networks

Opioid use disorder is a medical condition with major social and economic consequences. While ubiquitous physiological sensing technologies have been widely adopted and extensively used to monitor day-to-day activities and deliver targeted interventions to improve human health, the use of these technologies to detect drug use in natural environments has been largely underexplored. The long-term goal of our work is to develop a mobile technology system that can identify high-risk opioid-related events (i.e., development of tolerance in the setting of prescription opioid use, return-to-use events in the setting of opioid use disorder) and deploy just-in-time interventions to mitigate the risk of overdose morbidity and mortality. In the current paper, we take an initial step by asking a crucial question: Can opioid use be detected using physiological signals obtained from a wrist-mounted sensor? Thirty-six individuals who were admitted to the hospital for an acute painful condition and received opioid analgesics as part of their clinical care were enrolled. Subjects wore a noninvasive wrist sensor during this time (1-14 days) that continuously measured physiological signals (heart rate, skin temperature, accelerometry, electrodermal activity, and interbeat interval). We collected a total of 2070 hours (≈ 86 days) of physiological data and observed a total of 339 opioid administrations. Our results are encouraging and show that using a Channel-Temporal Attention TCN (CTA-TCN) model, we can detect an opioid administration in a time-window with an F1-score of 0.80, a specificity of 0.77, sensitivity of 0.80, and an AUC of 0.77. We also predict the exact moment of administration in this time-window with a normalized mean absolute error of 8.6% and R ² coefficient of 0.85.

Random urine drug testing among patients receiving opioid therapy for cancer pain

BACKGROUND

There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics.

METHODS

Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU.

RESULTS

In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01).

CONCLUSIONS

Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

Design and conduct of confirmatory chronic pain clinical trials

The purpose of this article is to provide readers with a basis for understanding the emerging science of clinical trials and to provide a set of practical, evidence-based suggestions for designing and executing confirmatory clinical trials in a manner that minimizes measurement error. The most important step in creating a mindset of quality clinical research is to abandon the antiquated concept that clinical trials are a method for capturing data from clinical practice and shifting to a concept of the clinical trial as a measurement system, consisting of an interconnected set of processes, each of which must be in calibration for the trial to generate an accurate and reliable estimate of the efficacy (and safety) of a given treatment. The status quo of inaccurate, unreliable, and protracted clinical trials is unacceptable and unsustainable. This article gathers aspects of study design and conduct under a single broad umbrella of techniques available to improve the accuracy and reliability of confirmatory clinical trials across traditional domain boundaries.

Alcohol and other substance use after liver transplant

In this article we tackle the controversial subject of alcohol and other substance use following liver transplantation (LT). Most of the literature on and importance of this topic pertains not to recreational use of alcohol or substances but to patients who have alcohol or substance use disorders (AUDs/SUDs). To understand these behaviors after such a lifesaving and resource-intensive procedure as LT necessitates an understanding of these disorders as chronic medical diseases. It also requires an awareness that management of these disorders begins before transplant, so we will briefly touch on considerations to prepare patients for the transplantation. Additionally, we review not only the rates of alcohol and substance use post-LT but strategies clinicians could adopt to identify and manage these events post-LT. Thus, we will summarize approaches for monitoring use and a range of therapeutic treatment options, including pharmacotherapy, to employ once use is discovered. While clinical gastroenterologists may be the primary clinicians responsible for the care of LT recipients, we emphasize a multidisciplinary team approach which, especially for the behavioral health components of the treatment, is likely to be the most successful. This article concludes with a summary of recommendations for clinicians working with these patients and possible future directions for both clinical care and research. While the bulk of the literature is on LT in the context of AUD, we review the smaller body of literature available on non-alcohol substance use.

Reducing Opioid Overprescribing by Educating, Monitoring and Collaborating with Clinicians: A Quality Improvement Study

Introduction

Multiple barriers have been described for reducing opioid prescribing by primary care providers. We describe a quality improvement report on the effects of a series of focused interventions on opioid prescribing after the release of the Centers for Disease Control and Prevention (CDC) guidelines while monitoring patient satisfaction.

Material and methods

The study began as an intervention project to inform and educate providers about the CDC’s guidelines and to improve adherence. A convenience sample of 165 providers from 33 outpatient clinics of a healthcare system was utilized. This quality improvement study compared a 20-month preintervention baseline period with a 16-month post-intervention period ending on December 31, 2017, using the health system’s electronic medical record. Interrupted time series analysis was used to assess the effect of the intervention on opioid prescribing. Providers were given quarterly individual reports on their prescribing patterns of schedule II opioids and comparing their prescribing patterns to their peers. Providers had access to educational opportunities for CDC guidelines, various aspects of safe opioid prescribing, and professionally written patient hand-outs about opioid risks and alternatives. Provider collaboration with patients for tapering opioids and collaboration with specialists in managing complex pain patients was encouraged. A total number of schedule II chronic opioid prescriptions per month was measured.

Results

The total schedule II opioid prescription rate was 19.6% lower than the average of the baseline. Every month after August 2016, there was a significant reduction of total schedule II opiate orders with a risk decrease of 2% [risk ratio (RR) 0.982; 95% confidence interval (CI) 0.976-0.989; p < 0.0001]. The patient satisfaction scores improved from 92.1 % in January 2015 to 95.1% by December 2017.

Discussion

We noticed an initial decrease in opioid prescribing with the release of the CDC guidelines. However, a greater decline in opioid prescribing was noted after distributing data to providers that compared their own opioid prescribing patterns to their peers. This data offered an opportunity for self-analysis to clinicians to justify the clinical reasons for writing more opioid prescriptions. Provider and patient education on the benefits of opioid reduction enabled better collaboration and engagement in shared decision making with a detailed plan of gradual opioid reduction. Our study was limited by the inability to determine the most effective intervention as the interventions were initiated as a bundle in our healthcare system. Indications for opioid therapy such as pain management for cancer pain or palliative care versus chronic non-cancer pain were not available. The major adverse events related to opioid use, such as opioid overdose deaths and opioid use disorder, were not measured in this data source.

Conclusions

Opioid overprescribing was reduced by educating providers and patients, monitoring clinicians’ opioid prescribing patterns, and seeking physicians’ collaboration. Future healthcare initiatives can utilize similar methods to evaluate interventions impacting the opioid epidemic.

Urine Drug Testing in Cancer Pain Management

Urine drug test (UDT) is an effective tool used in chronic opioid therapy to ensure patient adherence to treatment and detect nonmedical opioid use. The two main types of UDT used in routine clinical practice are the screening tests or immunoassays and the confirmatory tests or laboratory-based specific drug identification tests such as gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or tandem mass spectrometry. UDT produces objective data on some nonmedical opioid use that may otherwise go undetected, such as the use of undisclosed medications, the nonuse of prescribed medications, and the use of illegal drugs. It allows clinicians to initiate an open and effective conversation about nonmedical opioid use with their patients. However, the test has certain limitations that sometimes compromise its use. Its interpretation can be challenging to clinicians because of the complexity of the opioid metabolic pathways. Clear guidelines or recommendations regarding the use of UDT in cancer pain is limited. As a result, UDT appears to be underused among patients with cancer pain receiving opioid therapy. More studies are needed to help standardize the integration and use of UDT in routine cancer pain management. IMPLICATIONS FOR PRACTICE: Despite its potential benefits, urine drug testing (UDT) appears to be underused among patients with cancer pain receiving opioid therapy. This is partly because its interpretation can be challenging owing to the complexity of the opioid metabolic pathways. Information regarding the use of UDT in opioid therapy among patients with cancer is limited. This review article will improve clinician proficiency in UDT interpretation and assist oncologists in developing appropriate treatment plans during chronic opioid therapy.

Practices and perceptions regarding intravenous opioid infusion and cancer pain management

BACKGROUND

In view of the recent opioid crisis, ways to promote safe and effective opioid-related practices are needed. Faster intravenous (iv) opioid infusion rates can result in increased adverse effects and risk for nonmedical opioid use. Data on best practices regarding safe iv opioid administration for cancer pain are limited. This study examined iv opioid bolus infusion practices and perceptions about opioids in cancer pain among 4 groups of inpatient oncology nurses.

METHODS

An anonymous cross-sectional survey was conducted among oncology nurses working in medical, surgical, intensive care unit (ICU), and emergency department (ED) settings. An iv opioid bolus infusion speed less than 120 seconds was considered too fast.

RESULTS

The participant response rate was 59% (731 of 1234). Approximately 58%, 54%, and 58% of all nurses administered morphine, hydromorphone, and fentanyl, respectively, in less than 120 seconds. The median morphine infusion speeds were 55, 60, 60, and 85 seconds for ICU, surgical, ED, and medical unit nurses, respectively (P = .0002). The odds ratios for infusing too fast were 2.04 and 2.52 for ED (P = .039) and ICU nurses (P = .003), respectively, in comparison with medical unit nurses, and they were 0.27 and 0.18 with frequent (P = .003) and very frequent use of a timing device (P = .0001), respectively, in comparison with no use.

CONCLUSIONS

More than half the nurses working in the inpatient setting reported administering iv opioids too fast. ICU nurses administered opioids the fastest. Nurses who frequently used a timing device were less likely to infuse too fast. Further research is needed to standardize and improve the safe intermittent administration of iv opioids to patients with cancer.

Storage of urine specimens in point of care (POC) urine drug testing cups reduces concentrations of many drugs

BACKGROUND

Many clinical toxicology laboratories receive urine specimens in urine cups that contain point of care (POC) drug testing strips. We conducted this study to evaluate the effect on the stability of commonly measured drugs in the clinical toxicology laboratory when urine is exposed to POC urine drug testing cups.

METHODS

Drug free urine was spiked with 85 drugs that were measured by a validated liquid chromatography mass spectrometry (LCMS) method after exposure to POC urine drug testing cups at ambient and 2-6 °C temperatures. Alterations ≥20% were defined as significant changes in the drugs concentration.

RESULTS

Concentrations of amitriptyline, cyclobenzaprine, fentanyl, fluoxetine, flunitrazepam, nortriptyline, paroxetine, and sertraline were significantly reduced when urine specimens were stored inside POC urine drug testing cups for 24 h at ambient temperature. Storage of urine in urine chemistry dipsticks reduced the concentration of several drugs. When spiked urine was exposed to an increasing number of POC urine drug testing strips, the concentrations of some drugs were reduced in a dose-dependent manner. The drugs that were absorbed by POC urine drug testing strips were partially back extracted from the strips.

CONCLUSION

Exposure of urine specimens to POC urine drug testing strips reduces the concentration of several drugs measured by LCMS method.

Cannabis Legalization Does Not Influence Patient Compliance with Opioid Therapy

BACKGROUND

Prescription opioid use and opioid related deaths continue to increase nationwide. Several states have adopted legislation allowing for recreational use of cannabis. Little is known about how recreational cannabis laws impact compliance in chronic pain patients who have been prescribed opioid therapy. The goals of this study were to (1) retrospectively assess the effect of cannabis use on compliance with opioid therapy in a high-risk patient population and (2) determine the impact of legalization of recreational cannabis on patients prescribed therapeutic opioids.

METHODS

We conducted a retrospective cohort study on results from a "high-risk" urine drug testing panel. Results from 1 year before and 1 year after initiation of recreational cannabis legislation were analyzed. This testing panel included qualitative assays for cannabinoids and 9 other common drugs of abuse in addition to a quantitative LC-MS/MS assay for 23 different opioids and metabolites. Opioid compliance was assigned by reviewing pathologists' interpretations.

RESULTS

In the pre-legalization period, 1776 panels were performed, and in the post-legalization, 1648 panels were performed. An increase (6%) in the rate of positive cannabinoids screening results was observed after legalization of recreational cannabis; however, the overall compliance rate was consistent.

CONCLUSIONS

The results of this study suggest that legalization of recreational cannabis does not affect compliance rate in patients treated with opioid therapy for chronic pain.

Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations

Objective

To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids.

Methods

An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations.

Results

Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment.

Conclusions

Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain.

Substance-related disorders: A review of prevalence and correlates among patients with chronic pain

Over the past few decades, research has revealed high rates of substance-related disorders among patients with chronic pain. In addition to their potentially deleterious health consequences, substance-related disorders have consistently been associated with negative pain-related outcomes among patients with chronic pain. The goal of this narrative review was to provide an overview of studies that have examined the prevalence and correlates of substance-related disorders among patients with chronic pain. A particular focus was placed on opioids, sedatives/hypnotics, cannabis, tobacco, and alcohol given that these substances have received the bulk of research attention among patients with pain. Research conducted to date suggests that a host of biological and psychological factors are likely to contribute to the elevated rates of substance-related disorders among patients with chronic pain. In this review, in addition to reviewing the prevalence and correlates of substance-related disorders among patients with pain, we briefly discussed the changes that were recently made from the DSM-4 to the DSM-5 in the diagnostic criteria for substance-related disorders, and the implications of these changes for the assessment of patients with chronic pain. We also provided a brief overview of instruments that can be used for the assessment of these disorders in clinical and research settings.

Development and Validation of an Eight-Item Brief Form of the SOAPP-R (SOAPP-8)

Objective

Although the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) has become a widely used screener for aberrant opioid-related behavior in adults, the length of the instrument may limit its utility. The purpose of the current study was to develop a short form of the SOAPP-R by retaining as few items as possible while maximizing predictive accuracy.

Methods

Participants (N = 555), recruited from pain clinics, completed the 24-item SOAPP-R and participated in a five-month follow-up visit to evaluate aberrant drug-related behaviors. Opioid aberrant-related behavior was determined through self-report, physician report, and urine toxicology screen. The optimal subset of SOAPP-R items to predict aberrant opioid-related behavior was identified empirically by employing the LASSO selection method and the leave-one-out cross-validation (LOOCV) method offered in the GLMSELECT procedure in SAS 9.4 in conjunction with content expertise.

Results

Eight items were identified before the selection method stopped. The receiver operating characteristic curve generated from the predicted probabilities from the model produced an area under the curve (AUC) value greater than the AUC value produced by the 24-item SOAPP-R total score and yielded a sensitivity of 0.74 and a specificity of 0.66.

Conclusions

These results provide strong preliminary support for the SOAPP-8 as a brief screening tool of aberrant opioid-related behavior in chronic pain patients.

Analytical Considerations When Developing an LC-MS/MS Method for More than 30 Analytes

BACKGROUND

While validation of analytical (LC-MS/MS) methods has been documented in any number of articles and reference texts, the optimal design and subsequent validation of a method for over 30 analytes presents special challenges. Conventional approaches to calibration curves, controls, and run time are not tenable in such methods. This report details the practical aspects of designing and implementing such a method in accordance with College of American Pathologists validation criteria.

METHODS

Conventional criteria were followed in the design and validation of a method for 34 analytes and 15 internal standards by LC-MS/MS. These criteria are laid out in a standard operating procedure, which is followed without exception and is consistent with College of American Pathologists criteria.

RESULTS

The method presented herein provides quality results and accurate medication monitoring. The method was optimized to negate interferences (both from within the method and from potential concomitant compounds), increase throughput, and provide reproducible quality quantification over relevant analyte concentrations ranges.

CONCLUSIONS

The method was designed primarily with quality and accurate medication monitoring in mind. The method achieves these goals by use of novel approaches to calibration curves and controls that both improve performance and minimize risk (financial and operational). As automation and LC-MS/MS equipment continue to improve, it is expected that more methods like this one will be developed.

Opioid Medications in the Management of Chronic Abdominal Pain

PURPOSE OF REVIEW

Chronic abdominal pain is a complex medical condition. The causes of chronic abdominal pain are extremely diverse ranging from chronic pancreatitis, Crohn's disease, to chronic pain with no clear etiology. Treatment of chronic abdominal pain remains a challenge in our clinical practice. While current interventions with celiac plexus blocks and pain medications provide some relief for these patients, but these treatments are typically less efficacious and limited by various adverse effects. Opioid medications are commonly used to manage chronic pain syndromes that are refectory to other pain management interventions. The potential problems related to opioids include misuse, abuse, constipation, nausea pruritus, et al. Moreover, according to the recent centers for disease (CDC) control report, opioid abuse has reached epidemic proportions in the USA (LJ P. Centers for Disease Control and Prevention. 2016) and accounted for 28,000 deaths in 2014. Rudd et al. (MMWR Morb Mortal Wkly Rep 64(50-51):1378-82, 2016) Given this current situation, it is apparent that a careful review of clinical evidences supporting the use of opioid medications is necessary to guide our treatment approaches in the management of complex chronic abdominal pain patients. This review is set out to analyze efficacy of opioid medications for chronic abdominal pain.

RECENT FINDINGS

The literature referenced was obtained via a computer search with Google Scholar, Pubmed, Medline, and EMbase. The search terms used included Opioid, Oxycodone, Buprenorphine, Morphine, Fentanyl, Oxymorphone, Hydromorphone, chronic abdominal pain, Crohn's disease, and pancreatitis. All studies were considered eligible for inclusion if they were clinical studies evaluating the efficacy of opioid medications for chronic abdominal pain. Two studies were found according to these criteria. Chronic abdominal pain is a challenging medical condition in our daily practice. This condition often requires opioid medications when other treatments fail. This review provided very limited clinical evidence to support long-term opioid use for chronic abdominal pain. Given recent CDC report of opioid epidemic, it is prudent to use the best medical practice with appropriate evaluation of psychological comorbidities, urine drug screening, prescription drug monitor, and opioid treatment agreements to minimize adverse side effects related to opioids. Furthermore, well-designed clinical trials are needed to evaluate the effectiveness of long-term use of opioid medications, and more clinical research on which opioid medication is more effective for chronic abdominal pain.

Metabolic Patterns of Fentanyl, Meperidine, Methylphenidate, Tapentadol and Tramadol Observed in Urine, Serum or Plasma

Drug testing is a useful tool to identify drug use or monitor adherence to prescription drugs. The interpretation of drug results can be complicated based on the pattern and proportional concentrations of drugs and/or drug metabolite(s). The purpose of this retrospective study was to detect the positivity rates and metabolic patterns of five prescription drugs, including fentanyl, meperidine, methylphenidate, tapentadol and tramadol. Retrospective data were retrieved from the laboratory information system in a national reference laboratory. Drug testing was performed using four mass spectrometry methods that were validated for clinical use. For urine specimens, the positivity rate was the highest for methylphenidate (62.3%, n = 2,489), followed by tramadol (43.7%, n = 3,483), fentanyl (41.9%, n = 4,657), tapentadol (37.9%, n = 736) and meperidine (8.3%, n = 138). Among positive samples, both parent drug and metabolite(s) was detectable in 94.9% of meperidine samples, 94.5% of tramadol samples, 93.8% of fentanyl samples, 89.9% of methylphenidate and 86.6% of tapentadol samples. For serum or plasma specimens, the positivity rate was the highest for tapentadol (75.0%, n = 39), followed by methylphenidate (74.2%, n = 569), fentanyl (53.6%, n = 113), meperidine (41.9%, n = 18) and tramadol (28.9%, n = 213). Similar metabolic patterns were found in serum or plasma. Of positive results, both parent drug and metabolite(s) were found in 94.7% of fentanyl samples, 83.3% of meperidine samples, 79.6% of methylphenidate samples, 53.8% of tapentadol samples and 44.1% of tramadol samples. Our data demonstrates the metabolic patterns of five drugs from a random urine or serum/plasma collection in patients that have been prescribed these medications. The data presented can be used to guide clinicians in determining drug adherence by assessing the positivity rates of the parent drug and corresponding metabolite(s).

Rapid Assessment of Drugs of Abuse

Laboratory testing for drugs of abuse has become standard practice in many settings both forensic and clinical. Urine is the predominant specimen, but other specimens are possible including hair, nails, sweat, and oral fluid. Point-of-care test kits provide for rapid analysis at the site where specimens are collected allowing for immediate action on the results. POCT is based on immunochromatography where the drug in the patient's sample competes with drug and antibody conjugates in the test to develop or block the development of a colored line. Most POCTs are visually interpreted in a few minutes. The potential for false positives is possible due to drug cross-reactivity with the antibodies in the test. False negatives are also possible due to dilution of the sample and the potential for adulteration or sample substitution by the patient. POCT shows more variability than central laboratory testing because of the variety of operators involved in the testing process, but POCT has good agreement for most tests with mass spectrometry provided comparable cutoffs and cross-reactivity of drugs/metabolites are considered. Validation of the test performance with the intended operators will identify potential interferences and operational issues before implementing the test in routine practice. POCT offers faster turnaround of test results provided the limitations and challenges of the test are considered.

Suitability of the DRI Hydrocodone/Hydromorphone Immunoassay in the Clinical Environment at a Lower Cutoff: Validation With LC-MS/MS Analysis

BACKGROUND

We evaluated the analytical performance of the DRI hydrocodone/hydromorphone assay by comparing semiquantitative values obtained by this assay with values obtained by a liquid chromatography combined with tandem mass spectrometry (LC-MS/MS) method. We also evaluated the possibility of lowering the cutoff of the DRI assay from 300 to 100 ng/mL.

METHODS

We compared semiquantitative values obtained by the DRI assay in 97 specimens with values obtained by the LC-MS/MS method including 10 specimens containing hydrocodone and/or hydromorphone concentrations between 105.0 and 145.0 ng/mL (determined by LC-MS/MS) to determine the sensitivity at 100 ng/mL. In addition, several opioids at a concentration of 5000 ng/mL were also analyzed by the DRI assay to determine its specificity.

RESULTS

We observed no false-negative result using the DRI immunoassay in 96 specimens that showed semiquantitative values at 100 ng/mL or higher. However, one specimen containing 110 ng/mL of hydrocodone was false negative with the DRI assay (semiquantitative value 88 ng/mL, below 100 ng/mL cutoff). The semiquantitative values produced by DRI showed poor correlation with values determined by the LC-MS/MS method. The sensitivity of the DRI assay at 100 ng/mL was 90%, and the assay was very specific showing minimal cross-reactivity only with oxycodone and oxymorphone.

CONCLUSIONS

DRI immunoassay for hydrocodone/hydromorphone is a cost-effective method of screening urine specimens in the clinical environment at a lower cutoff of 100 ng/mL.

Interviewing and Urine Drug Toxicology Screening in a Pediatric Pain Management Center: An Analysis of Analgesic Nonadherence and Aberrant Behaviors in Adolescents and Young Adults

OBJECTIVES

Many adolescents and young adults report having chronic pain. Urine drug toxicology (UDT) is not routinely used in the pediatric pain management population, despite more routine use in adults with pain, particularly those prescribed opioids. As a first step toward establishing monitoring practices in pediatric and adolescent pain management, the present study evaluated the role of UDT in conjunction with a standard clinical interview in identifying the rate of adherence to an established analgesic regimen. The study also aimed to assess the use of UDT in identifying possible aberrant behaviors in this population.

METHODS

Data were acquired from a convenience sample of 50 pediatric and adolescent pain management initial consultations, during which a clinical interview and UDT were conducted. Data were analyzed to determine adherence to an established analgesic prescription regimen, and for identification of aberrant behaviors including concurrent use of illicit substances and prescription medication misuse. Other pertinent demographic and clinical factors were examined as factors in adherence.

RESULTS

Opioid medications were prescribed for 42% of the sample receiving pain medications, and 22% of the sample was nonadherent to their prescription analgesic regimen. Factors associated with a higher likelihood of nonadherence were an older age and having an opioid prescription. The majority (90%) of those nonadherent to their analgesic regimen displayed some form of aberrant behavior. Among the nonadherent patients, 50% were identified by UDT alone, and 50% were identified by self-report during the clinical encounter.

CONCLUSIONS

These results highlight the challenges of identifying nonadherence to a prescription regimen among adolescents with chronic pain. In addition, this preliminary work suggests that UDT could be used in conjunction with careful clinical interviewing to substantiate patient report and increase the likelihood of detecting analgesic nonadherence and aberrant behaviors.

Discordant reporting of nonmedical opioid use in a nationally representative sample of US high school seniors

BACKGROUND

Nonmedical opioid use has become a major public health concern due to increases in treatment admissions, overdoses, and deaths. Use has also been linked to heroin initiation. Reliable data on nonmedical opioid use are needed to continue to inform prevention.

OBJECTIVE

To determine the prevalence and correlates of discordant self-report of nonmedical use of opioids in a national sample.

METHODS

Utilizing a nationally representative sample of 31,149 American high school seniors in the Monitoring the Future study (2009-2013), discordant responses between self-reported 12-month nonmedical opioid use and self-reported 12-month nonmedical Vicodin and OxyContin use (reporting Vicodin/OxyContin use, but not reporting "opioid" use) were assessed. We also used multivariable logistic regression to determine the characteristics of students who were most likely to provide a discordant response.

RESULTS

37.1% of those reporting nonmedical Vicodin use and 28.2% of those reporting nonmedical OxyContin use did not report overall nonmedical opioid use. Prevalence of nonmedical opioid use (8.3%) would increase when factoring in Vicodin, OxyContin, or both, by 2.8%, 1.3%, and 3.3%, respectively. Females were more likely to provide a discordant response to Vicodin and highly religious students were more likely to provide a discordant response regarding OxyContin use. Those who reported cocaine or nonmedical tranquilizer use were at consistently low odds for discordant responses. Nonmedical amphetamine users were at low odds for providing a discordant Vicodin response.

CONCLUSION

Prevalence of nonmedical opioid use may be underreported on some surveys, particularly among specific subpopulations. Further research on the effect of question order and skip-patterns (e.g., "gate" questions) is needed. Reliable data on nonmedical opioid use are needed to continue to accurately inform prevention.

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic

BACKGROUND

Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer.

METHODS

A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison.

RESULTS

Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%).

CONCLUSIONS

UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.

Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication

During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.

Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care

Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.

Impact of an Electronic Pain and Opioid Risk Assessment Program: Are There Improvements in Patient Encounters and Clinic Notes?

OBJECTIVE

A comprehensive electronic self-report assessment, called PainCAS^® (Clinical Assessment System), was developed and implemented in three clinics. PainCAS captures demographic information, pain assessment, quality-of-life variables, and contains validated, electronic versions of screeners for risk of aberrant opioid-related behaviors (the SOAPP and COMM). This investigation sought to determine the impact of PainCAS on documentation of pain and opioid risk evaluations. Exploratory hypotheses examined changes in the content of the patient-provider interaction and any impact on outcome.

METHODS

In study 1, chart reviews were conducted between pain patients who completed the electronic program (N = 89) and controls who represented standard of care (N = 120). In study 2, two groups of chronic pain patients (treatment-as-usual Control condition = 75, PainCAS Experimental condition = 72) were interviewed after completing their index clinic visit and completed mailed questionnaires 3 months later.

RESULTS

Results revealed significantly more key, pain-relevant chart elements documented in charts of patients who completed the PainCAS than those using a traditional paper questionnaire (Study 1; <0.001). In Study 2, the Experimental group reported more discussion about legal issues, substance use history, and medication safety compared with the Control group (p < 0.05). Satisfaction questionnaire responses supported provider and patient perceived benefit from using PainCAS. However, as expected, no differences were found between conditions on outcome measures of pain, mood, and function.

CONCLUSIONS

Results indicate that use of the PainCAS electronic pain assessment improves documentation of chart elements in clinic notes and is associated with increased discussion of key, pain-relevant topics during the clinical visit.

Profiles of Urine Drug Test in Clinical Pain Patients vs Pain Research Study Subjects

OBJECTIVE

To examine similarities and differences in urine drug test (UDT) results in clinical pain patients and pain subjects participating in pain research studies.

DESIGN

An observational study with retrospective chart review and data analysis.

METHODS

We analyzed 1,874 UDT results obtained from 1) clinical pain patients (Clinical Group; n = 1,529) and 2) pain subjects consented to participate in pain research studies (Research Group; n = 345). Since several medications such as opioids used in pain management are drugs of abuse (DOA) and can result in a positive UDT, we specifically identified those cases of positive UDT due to nonprescribed DOA and designated these cases as positive UDT with DOA (PUD).

RESULTS

We found that 1) there was a higher rate of PUD in clinical pain patients (41.3%) than in pain research study subjects (14.8%); 2) although subjects in the Research Group were informed ahead of time that UDT will be conducted as a screening test, a substantial number (14.8%) of pain research study subjects still showed PUD; 3) there were different types of DOA between clinical pain patients (cannabinoids as the top DOA) and research study subjects (cocaine as the top DOA); and 4) a common factor associated with PUD was opioid therapy in both Clinical Group and Research Group.

CONCLUSION

These results support previous findings that PUD is a common finding in clinical pain patients, particularly in those prescribed opioid therapy, and we suggest that UDT be used as routine screening testing in pain research studies.

Opioid Analgesics

Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for patients with chronic pain who are at risk for opioid misuse are presented. Specific behavioral interventions designed to improve adherence with prescription opioids among persons treated for chronic pain, such as frequent monitoring, periodic urine screens, opioid therapy agreements, opioid checklists, and motivational counseling, are also reviewed. Use of state-sponsored prescription drug monitoring programs is also encouraged. Areas requiring additional investigation are identified, and the future role of abuse-deterrent opioids and innovative technology in addressing issues of opioid therapy and pain are presented.

Opioids for chronic noncancer pain

Opioids are powerful medications with a history that includes use for pain relief and, at times, addiction. This history of therapy versus drug abuse continues to cloud their prescription today, despite reports of effective treatment for the chronic pain that certain diseases can bring. Here, Drs Antoin and Beasley review the use of opioid agents in medicine, highlight the importance of proper patient selection and education in their use, and convey how opioids can be a viable option today for successful therapy for chronic noncancer pain.

Do Palliative Care Clinics Screen for Substance Abuse and Diversion? Results of a National Survey

BACKGROUND

Opioids are the mainstay of treatment of cancer pain. With increased use there have been concerns about rising rates of prescription drug abuse and diversion. Although there has been an increase in research and practice guidelines about the scope of the problem for chronic, nonmalignant pain, less information is available about both the frequency of the problem and current practices regarding screening for substance abuse and diversion in patients and family members seen in palliative care clinics.

OBJECTIVE

The aim of this study was to evaluate the degree to which palliative programs felt that substance abuse and diversion was an issue, and to identify practices regarding care of patients with potential substance misuse issues.

METHODS

We sent a survey regarding substance abuse perception, policies, training, and screening to 94 accredited palliative medicine fellowship program directors as obtained by the Accreditation Council for Graduate Medical Education (ACGME) directory.

RESULTS

We received usable responses from 38 (40.4%) programs. Policies for screening patients (40.5%) or family members (16.2%), dealing with diversion (27%), and use of a screening tool (32.4%) were reported infrequently. Despite this, one-half of respondents indicated that substance abuse and diversion was an issue for their clinics, with only 25% indicating substance abuse was not an issue. Additionally, the majority of fellows (83%) and about half (47%) of staff received mandatory training for dealing with substance misuse. All programs provided some screening of patients, with 48.7% screening all patients for abuse. Screening of family members was relatively rare, as was routine use of the urine drug screen (UDS).

CONCLUSION

Despite increased concerns about substance abuse, the majority of programs did not have substance abuse and diversion policies or report screening all patients, with screening of caregivers rarely reported. Consensus guidelines addressing substance abuse and diversion for palliative patients are needed to address this growing problem.

Validation of a brief Opioid Compliance Checklist for patients with chronic pain

There has been a need for a brief assessment tool to determine compliance with use of prescribed opioids for pain. The purpose of this study was to develop and begin the validation of a brief and simple compliance checklist (Opioid Compliance Checklist [OCC]) for chronic pain patients prescribed long-term opioid therapy. A review of the literature of opioid therapy agreements led to a 12-item OCC that was repeatedly administered to 157 patients who were taking opioids for chronic pain and followed for 6 months. Validation of the OCC was conducted by identifying those patients exhibiting aberrant drug-related behavior as determined by any of the following: positive urine toxicology screen, a positive score on the Prescription Drug Use Questionnaire interview or Current Opioid Misuse Measure, and/or ratings by staff on the Addiction Behavior Checklist. Of the original 12 items, 5 OCC items appeared to best predict subsequent aberrant behaviors based on multivariate logistic regression analyses (cross-validated area under the receiver operating characteristic curve = .67). Although further testing is needed, these results suggest that the OCC is an easy-to-use, promising measure in monitoring opioid adherence among persons with chronic pain.

PERSPECTIVE

This study presents validation of a brief 5-item compliance checklist for use with chronic pain patients prescribed long-term opioid therapy. This measure asks patients about aberrant drug-related behavior over the past month, and any positive response indicates problems with adherence with opioids. Further cross-validation testing is needed.

Future applications of high-resolution MS to meet the demands for pain management drug testing

Urine specimens submitted for pain management drug testing often contain multiple psychotherapeutic drugs, in addition to opioids. Immunoassay-based screen-and-confirm approaches typically used for clinical drug testing have limited sensitivity to detect therapeutic concentrations of many drugs prescribed in pain management and do not differentiate between drugs in the same class. In addition, screening for all the various illicit and prescription drugs that may be present in the pain management population requires as many as 10–20 individual immunoassays. High-resolution MS approaches have the potential to transform the way clinical drug testing is performed for pain management.

Systematic evaluation of "compliance" to prescribed treatment medications and "abstinence" from psychoactive drug abuse in chemical dependence programs: data from the comprehensive analysis of reported drugs

This is the first quantitative analysis of data from urine drug tests for compliance to treatment medications and abstinence from drug abuse across “levels of care” in six eastern states of America. Comprehensive Analysis of Reported Drugs (CARD) data was used in this post-hoc retrospective observational study from 10,570 patients, filtered to include a total of 2,919 patients prescribed at least one treatment medication during 2010 and 2011. The first and last urine samples (5,838 specimens) were analyzed; compliance to treatment medications and abstinence from drugs of abuse supported treatment effectiveness for many. Compared to non-compliant patients, compliant patients were marginally less likely to abuse opioids, cannabinoids, and ethanol during treatment although more likely to abuse benzodiazepines. Almost 17% of the non-abstinent patients used benzodiazepines, 15% used opiates, and 10% used cocaine during treatment. Compliance was significantly higher in residential than in the non-residential treatment facilities. Independent of level of care, 67.2% of the patients (n = 1963; P<.001) had every treatment medication found in both first and last urine specimens (compliance). In addition, 39.2% of the patients (n = 1143; P<.001) had no substance of abuse detected in either the first or last urine samples (abstinence). Moreover, in 2010, 16.9% of the patients (n = 57) were abstinent at first but not at last urine (deteriorating abstinence), the percentage dropped to 13.3% (n = 174) in 2011; this improvement over years was statistically significant. A longitudinal analysis for abstinence and compliance was studied in a randomized subset from 2011, (n = 511) representing 17.5% of the total cohort. A statistically significant upward trend (p = 2.353×10⁻⁸) of abstinence rates as well as a similar but stronger trend for compliance ((p = 2.200×10⁻¹⁶) was found. Being cognizant of the trend toward drug urine testing being linked to medical necessity eliminating abusive screening, the interpretation of these valuable results require further intensive investigation.

Abuse liability measures for use in analgesic clinical trials in patients with pain: IMMPACT recommendations

Assessing and mitigating the abuse liability (AL) of analgesics is an urgent clinical and societal problem. Analgesics have traditionally been assessed in randomized clinical trials (RCTs) designed to demonstrate analgesic efficacy relative to placebo or an active comparator. In these trials, rigorous, prospectively designed assessment for AL is generally not performed. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) convened a consensus meeting to review the available evidence and discuss methods for improving the assessment of the AL of analgesics in clinical trials in patients with pain. Recommendations for improved assessment include: (1) performing trials that include individuals with diverse risks of abuse; (2) improving the assessment of AL in clinical trials (eg, training study personnel in the principles of abuse and addiction behaviors, designing the trial to assess AL outcomes as primary or secondary outcome measures depending on the trial objectives); (3) performing standardized assessment of outcomes, including targeted observations by study personnel and using structured adverse events query forms that ask all subjects specifically for certain symptoms (such as euphoria and craving); and (4) collecting detailed information about events of potential concern (eg, unexpected urine drug testing results, loss of study medication, and dropping out of the trial). The authors also propose a research agenda for improving the assessment of AL in future trials.

The association between catastrophizing and craving in patients with chronic pain prescribed opioid therapy: a preliminary analysis

BACKGROUND

A growing number of studies have shown that opioid craving (i.e., the perceived need or desire to consume opioids) is one of the strongest determinants of prescription opioid misuse in patients with chronic pain prescribed opioid therapy. To date, however, the factors that are associated with craving in patients with pain remain largely unexplored. Based on previous research, there is reason to believe that catastrophizing might be associated with heightened opioid craving.

OBJECTIVES

To test the hypothesis that catastrophizing would be associated with heightened craving in patients with chronic pain prescribed long-term opioid therapy.

DESIGN AND SUBJECTS, AND METHODS

In this cross-sectional study, 109 patients with chronic pain were asked to provide self-reports of catastrophizing and craving. Patients also provided self-reports of pain intensity and depressive symptoms.

RESULTS

We found that higher levels of catastrophizing were associated with higher levels of craving. Importantly, results of a regression analysis revealed that the association between catastrophizing and craving remained significant even after controlling for a host of demographic (i.e., age, sex), psychological (i.e., depressive symptoms), medical (i.e., pain intensity, pain duration), and medication regimen (i.e., opioid doses) variables.

CONCLUSIONS

Our preliminary findings provide valuable new insights into the determinants of craving in patients with pain. The finding that catastrophizing was associated with craving even after controlling for a host of demographic, psychological, medical, and medication regimen variables is particularly striking, and raises questions concerning the factors that underlie the association between catastrophizing and craving in patients prescribed opioid therapy.

The challenges of LC–MS/MS analysis of opiates and opioids in urine

Opioids are some of the most commonly prescribed and abused drugs around the world. Primarily used for anesthesia or pain management, other opioids can also be used in the treatment of opioid addiction. Given these facts, clinicians often randomly test or monitor their patients to determine compliance or abstinence from these drugs via immunoassay methods. When a positive screen is obtained, a confirmatory assay is carried out and although the gold standard has been GC–MS, LC–MS/MS is fast becoming a valid and popular alternative. This review will discuss opioids, the complex metabolic pathways, the measurement of these drugs, the challenges involved and, finally, will describe some LC–MS/MS methods published from 2003 until 2013.