Prescription Opiate Series: Part 2 – Monitoring Use

As discussed in part 1 of this series on Prescription Opiates, the number of people surrounding us that covertly struggle with an opiate addiction is startling and extremely troublesome. Even though the number of people seeking treatment has increased, over the past decade, overdose deaths from prescription painkillers now exceed the number of motor-vehicle related deaths. Opiate abuse or addiction often goes unnoticed until it is tragically too late. The treatment of opiate abuse starts with the ability to identify potential abuse, requiring familiarity with the signs and symptoms. But even after you identify a client’s suspected abuse or addiction, what’s the next step to effectively addressing and beginning to treat opiate abuse?

Start by sharing with your client that you are concerned about your client’s health.  Ask your client if they are using any substances and if they would like help to stop using such substances.  Unfortunately, a long list of studies demonstrate that clients will only share a portion of their story and withhold information that is essential to helping the client overcome opiate abuse.  Nonetheless, a conversation is a good first step and in some cases clients will open up and start the recovery process.  There are a number of clinical surveys or screening questioners that can help facilitate this conversation.

Next, verify your concerns and the client’s statement with a drug test that includes both illicit and prescribed opiates, as well as synthetic opiates.  An initial comprehensive opiate screen provides objective, actionable information that when combined with clinical judgment help shape the client’s care plan.  Some clinicians opt to rely on clinical judgement alone contradicting evidenced based practices that demonstrate that clients benefit when clinicians incorporate measurement based care.  Treating opiate addiction absent drug screens is the equivalent of treating hypertension absent a blood pressure cuff.  With objective information in hand you are better equipped to execute on care plans that will drive improved outcomes in the form of lower relapse rates and improved housing, education, and employment rates.

Now that you have conducted a comprehensive opiate screen (as described below), you are in a position to tailor future drug tests to the specific needs of the individual client.  Evidenced based practices show that clients subject to random testing of at least 2x per week are more likely to develop lasting coping and refusal skills to future use.  Ongoing random testing provided in a pro-social manner (carrot not stick) induces client engagement, confirms or shapes clinical judgment, provides objective information on a client’s progress or lack thereof, and equips the clinician to challenge and resolve client denial of ongoing use.

So, what exactly is a comprehensive opiate screen? Most drug tests detect common opiates like codeine, heroin, and morphine, but are incapable of distinguishing heroin from other substances.  These basic opiate tests are generally not capable of detecting the most commonly prescribed opiate drugs that lead to abuse, including oxycodone, oxymorphone, hydrocodone, and hydromorphone.  Additionally, the abuse of synthetic opiates like buprenorphine, fentanyl, meperdine, methadone, and tramadol is on the rise, and common opiate drug tests are incapable of detecting these substances. It is important to ensure the drug test you’re using to determine opiate use is capable of successfully detecting the substances of concern.  The following table provides a summary of the commonly abused opiates that should be incorporated into the drug tests used when caring for opiate addicted clients:

Table of commonly-abused opiates

As illustrated in the above table, the standard opiate test generally only detects three opiates. Also, standard opiate tests are incapable of distinguishing between these three substances. One option to identify all of these substances is to order a chromatography or confirmation test. However, confirmation tests are expensive. More importantly, the standard industry turnaround time for chromatography results is 3 to 5 days – Avertest reports chromatography results in 1 to 2 days – and opiate abuse requires timely intervention.  If you do not know the client’s substance of choice, a one-time comprehensive chromatography screen can equip you with the information necessary to design a custom opiate panel best suited for the client.  A better option that is more affordable and timely is to order an expanded opiate panel that is capable of detecting a broader range of opiates and rotate in a few synthetic substances for ongoing random tests.

For example, a client with a history of oxycodone abuse would be best served by an expanded opiate panel, a specific oxycodone test, and possibly a rotation of prescribed and synthetic opiates.  This panel configuration allows for: results reporting in one day; is economical and; clearly identifies oxycodone use.  The prescribed and synthetic opiate panel rotation is a key evidence-based practice proven to help clients develop coping and refusal skills to new substance use. Clients that struggle with opiate addiction often transition from a drug of choice to a similar substance to avoid detection. This is especially true when the client is subject to systematic substance monitoring.  Implementing a panel rotation will allow you to identify if a client migrates to a new opiate to avoid detection.

So how can you ensure you are detecting suspected opiate use? It’s vital to have access to a testing service capable of detecting a broad range of opiates. At a minimum, ensure you are conducting an expanded opiate test that is capable of detecting heroin, morphine, hydrocodone, hydromorphone, oxymorphone, and oxycodone.  Additionally, the ability to customize test panels to an individual client will allow you target the most appropriate substances.  Instead of testing for drugs not typically used by opiate abusers, you can customize testing and expand testing from common opiates class to prescription and synthetic opiates.  Since prescription and synthetic opiate testing is often more expensive, randomly rotating in these different substances on a per test basis allows you to effectively monitor use in a cost-efficient manner.

Awareness of the signs and symptoms combined with systematic substance use monitoring is imperative to address opiate abuse. For more information on opiate abuse and how to successfully monitor opiate use, please contact your laboratory or Avertest at info@avertest.com.