Many pain specialists follow the appropriate clinical practice guidelines and have pain contracts with their patients taking controlled substances. As part of those contracts, there is most often a clause about performing drug tests sporadically to ensure appropriate use. These drug tests performed in the provider office, while less expensive than the alternative tests sent out to a lab, can be used as an initial compliance tool, but these assay tests may be prone to error. If there are any inconsistent results (i.e. drugs showing up that aren’t prescribed or prescribed drugs not showing up) then the specimen should be sent for confirmation to a lab that can provide more specific results. These results can then be used by the provider to open a discussion with the injured worker concerning the effectiveness and safety of the drug regimen and compliance with prescribed instructions.
Recently, there was an injured worker whose drug test indicated separate positive results for both Opiates and Oxycodone. The prescribed drug regimen included Oxycodone only and the drug test identified the presence of Opiates as inconsistent and the sample was sent for confirmation to the lab. It is important to note that Oxycodone is metabolized differently than true Opiates (Morphine, Codeine, Hydrocodone, Heroin etc.) and appropriate drug tests will distinguish between the two and provide separate results for each category. In this instance, when the provider opened a discussion regarding the test results, the injured worker explained that he visited the emergency department and was prescribed a limited supply of Hydrocodone/Acetaminophen. This experience allowed the prescriber an opportunity to discuss the serious nature of these opioid medications and to review the contract and compliance to prescribed instructions for the injured worker’s drug regimen.
What should adjusters take away from this? Encourage the providers to have a contract in place when prescribing controlled medications and offer random drug testing with appropriate distinctions between Opiates and Oxycodone. Utilize confirmatory tests appropriately to reinforce compliance and reduce fraud, waste, abuse and misuse.
By: Sean D. Chitwood, PharmD, MBA