Drug Screening: Cost vs. Value

[BroncoPAS]

I am curious what your thoughts are on the future of drug screening for pain management patients? I have an interest in both sides of the equation (lab and clinical setting) so I wanted a non-biased view point. The following article provides a nice framework although there are many issues with it's quality that I'm sure you'll notice.

 

http://www.medscape.com/viewarticle/759524

[Guest Paula]

My clinic does not have many patients that we serve for PAIN management, but we have quite a few who are on stimulants for ADD/ADHD. We drug screen all of our patients, including children starting at about age 12 for drugs of abuse, who are in our ADD/ADHD program. Each adult patient and parents/guardians of underage patients sign a prescribing agreement before starting any scheduled drug (this does not include acute reasons for patients to be on an opiate, however). All of our patients follow up every three months for exam, discussion of meds, and a drug screen only if indicated. During the start of the program, a urine drug screen is ordered, and if there is any drug of abuse that should not be there, they are not accepted into the program until the drug screen is clear. The reason for this is that we conduct computerized testing for ADD/ADHD that assists with a diagnoses and do not want any substances to interfere with a valid test. Testing is not completed until the patient is clear of drugs of abuse.

 

Therein lies the rub. How often do we test the patient until they are clear? It is expensive and the clinic I am at does not make much money from testing since we are a FQHC and an Indian Health Service clinic, so if a patient is insured with private insurance, no problem. If not, we eat the tests. We are still in the process of working out the kinks and have many questions that we refer on to the lab that performs the confirmation once we have a positive POC test. We are challenged with appropriate testing, over testing, patients anger, and of course, tribal politics, which is a fact of life and we cannot get away from the council interfering with how we do medical care. That part of the issue is the worst and not likely to be something you will have to deal with in a pain management clinic.

 

In the last six months we have largely finalized our prescribing agreement. We have dismissed about 18 people from our program (out of about 70) for inability of the patient to comply with the agreement. Interestingly we have uncovered some of the patients have other issues that respond better to SSRI's and don't need the stimulants. It is an art and a science to practice this side of medicine and a background in psychiatry is needed (IMHO) to adequately and correctly treat our patients, and safely. This may not answer your questions and not quite the same topic as you posted.

 

Our lab tech, who has a bachelors in biology, was a teacher for a while, then got an engineering degree and now later in life, decided to pursue an area in medicine has been on the phone with the lab that does our POC testing confirmation. Our questions entail why do we get a positive POC test, and their lab gets negative? The answer is that the test really was positive but did not meet the minimum threshold to call it positive. They cannot answer why the test we get from their company flags it as positive on the POC test and meets the minimum threshold that they developed for the test. They refer our questions to their PhD and our lab tech will usually say to me "I hope the PhD guy doesn't call because I still can't get a straight answer from him".

 

You can see the challenges!

[donwinder]

We have just installed an in house lab for this. I work in interventional pain management. Worth every penny. We have found so many inconsistent results. It acts as a filter but also a tool to speak frankly to patients that may need rehab. Within the past couple months have helped three people connect to rehab for crystal meth abuse. There is also the liability issue. I feel like if I prescribe controlled substances it is just as important to monitor as meds for HTN, DM, depression, etc. I want to help patients but not allow them, on purpose or not, to get into serious problems with these medications.

 

As far as cost, we had a big issue when we first started doing frequent UA's. We used an extrernal lab who wascharging up to $800 for GSMC. Our in house is about $200 out-of-pocket. One insurance company charges patient about $100. Otherwise it is covered. We take this into account with the patients in the higher cost group, which are not many. There are effective ways to monitor with or without UDS. State drug monitoring sites, communicating with other providers, and being observant of patient's patterns and behaviors. Someone who is misusing will show themselves at one point.

[mxpac76]

I work part time in pain management. In addition I work in family practice where I see some pain patients. The feds (and lots of states) are putting a lot more scrutiny on prescriptions for pain meds. For your own protection, as well as the protection of your patients, you need to make sure that every patient has a pain contract in their chart. It is also wise to do the in-house dip urine fro drugs of abuse with any positives sent to an outside lab for confirmation. If for some reason you get audited, you will get dinged if you do not have signed pain contracts for all patients on long term opiates. The "ding" can be fairly substantial. It is also critical to do thorough documentation each visit including pain scale rating, actual PE, and what the pain folks I work with refer to as the four As - Affect - do they look depressed, etc.; Activity - are they more or less active than they were before the pain meds - this can also be termed Adequacy - are they getting sufficient relief; Aberrant behavior - any indications of abuse, diversion, etc.; and Adverse effects - side effects and what is being done for them if present. They also make it a rule that anyone who uses marijuana does not get chronic opiates, period. It does not matter if they have a medical marijuana card or are from Washington where they recently legalized it. The potential combination of opiates and marijuana exponentially ups your liability issues. It may sound mean but they stick with it and are very open with the requirement. Any recreational drug use is grounds for dismissal. The frequency of urine tests depends on their history of abuse or positive results. There are no early refills, not even if they present a police report showing purported theft. They put "must last until" and "do not fill before" on all opiate rx as I now do in my other jobs. It is your license and livelihood on the line. It is nice to be empathetic towards pain patients but not at the expense of your ability to practice. This is spoken both as a provider and as a back pain patient myself - which is how the clinic found me to work relief for their PAs. Hope this helps.

[crank]

Hi BronocoPAS,

Cost of the drug will be more based upon its value. If it cures the patients, then the value of the drug will be more, automatically cost will also be more. Customer needs to be satisfied in the terms of cost and value.

[cupojava]

Cost=expensive; Value=priceless. I check UDS for all patients that I prescribe controlled substances to. They are "controlled" for a reason. With OIG and DEA auditing what you do, you should be able to justify why you are prescribing. If a patient chooses to take illicit drug, that's their choice but it is my responsibility to not give them controlled substances along with it. First do no harm.