Oregon-based physician Alan Schwartzstein knows urine tests aren’t very popular in America at the moment, thanks in part to reports about hospitals using them to rack up medical bills. But he figures it’s a worthwhile cost to protect his patients from opioid addiction.
It couldn’t be less sexy as a tool in the fight against America’s opioid crisis, which killed 64,000 people in 2016 and was described by the U.S. Drug Enforcement Administration in 2015 as having reached “epidemic levels.” While debates rage over new opioid substitutes and technology-driven solutions, a parallel and low-tech war on the crisis is growing across America. More and more doctors are educating and arming themselves to better deal with opioid addiction. Researchers are tailoring questionnaires and screenings originally meant to trace other addictions such as alcoholism to help detect opioid abuse early. Health policy experts are recommending tweaking coercive “pain contracts” between doctors and patients — in which a patient accepts that they will lose medication under certain circumstances. And physicians are recommending urine tests at the risk of patients’ wrath.
American Academy of Family Physicians (AAFP) members reported completing more than 157,217 continuing medical education credits on opioid-related topics in 2017, up from 141,000 credits in 2016. According to the Substance Abuse and Mental Health Services Administration, certifications to provide medication-assisted treatments to opioid patients under the Drug Addiction Treatment Act (DATA) jumped from 25,000 in 2014 to 31,862 in 2016. Studies testing the efficacy of alcohol addiction–related screening questionnaires modified for the opioid epidemic also have gone up, as has research verifying the benefits of the Opioid Risk Tool (ORT) — a brief self-reporting tool used to test risk of opioid abuse in adults. And the number of urine tests in America has leaped from fewer than 2 million in 2004 to almost 12 million in 2014.
At this point, with the epidemic, I explain to my patients that this is simply a cost they’re gonna have to expect. Alan Schwartzstein, physician, speaking about urine tests
“At this point, with the epidemic,” says Schwartzstein, “I explain to my patients that this is simply a cost they’re gonna have to expect.”
Physicians and medical researchers say the full breadth of factors contributing to the crisis isn’t understood adequately by most Americans. Doctors have come under fire for the overprescription of opioids. After all, 36 studies have shown that at least 39 percent — and possibly as high as 86 percent — of heroin users started with opioids. But what about the rest? Many heroin overdoses don’t start with prescriptions — at least, not an addict’s own. The studies that suggested overprescription didn’t distinguish people who abuse their own medicines from those who swipe from a relative’s cabinet.
Since 2010, says Judith Paice, director of the Cancer Pain Program at Northwestern University, opioid deaths are linked more to illicit drugs like fentanyl and heroin. “People were pretty liberal with opioids,” says Courtney Kominek, a pain specialist with Truman Memorial Veterans’ Hospital, speaking in her individual capacity. “Now, as they say, the pendulum has swung.”
It may have, but doctors aren’t taking chances. And the lifeblood of their fight is a set of screens for addiction risk factors. Among the most popular of these tools are questionnaires. About half a dozen, such as the ORT, SOAPP-R and CAGE-AID (an adapted version of a four-question prompt originally designed to gauge alcoholism, which itself is a good predictor of opioid abuse), are becoming standard. The SOAPP-R tries to gauge how the patient feels about their use of medications, with questions like “How often have you felt a need for higher doses of medication to treat your pain?” It also gathers data on lifestyle habits that might lead to abuse. The ORT, among other things, tries to track any family history of substance abuse as a means of determining risk factors. The CAGE-AID captures how individuals in the patient’s life respond to alcohol or drug use. It asks, for instance: “Have people annoyed you by criticizing your drinking or drug use?”
They may sound boring, but the SOAPP-R and CAGE, for example, have a respective specificity (an accuracy rate with few false positives) of around 70 and 90 percent. In fact, CAGE-negative patients, scoring low on risks for opioid dependency, have been shown to get off opioid prescriptions nearly three times faster than CAGE-positive ones.
However, while questionnaires are accurate, “they aren’t lie-detector tests,” says Kominek.
Luckily, urine tests can be. Not only are they precise, but also at least one study, on Veterans Affairs patients, has shown that higher levels of implementation are associated with lower risks of suicide and overdose — although the question of whether wider testing among the general population would save lives is still contentious, requiring more evidence. For one thing, they can cost up to $1,000, says Schwartzstein, who’s also a speaker for the AAFP.
Opioid prescriptions may still be crucial, particularly for cancer patients, says Paice. Research results are more mixed for non-cancer pain patients: They can work over short periods of time in some cases, but prove relatively ineffective in others. A healthy doctor-patient relationship is key to ensuring that opioid prescriptions don’t lead to addictions. But that relationship has suffered in recent years as patients have complained about doctors misusing pain contracts to “fire” them, leaving them desperate. Now, health experts are devising altered versions of the contract that emphasize shared decision-making and trust-building. Yale internal medicine researcher Daniel Tobin, for instance, has led efforts to reframe the contract as a “controlled-substance agreement” that lists out common responsibilities — including discussions on dangers, costs and alternative medication options — apart from tasks the doctor and patient individually commit to.
Medical organizations are fighting for more education, for both doctors and patients. “I didn’t really get much education on pain management, or risk assessment, or identifying substance abuse disorder,” says Kominek. The AAFP, for example, recommends that more doctors get certified to be able to administer medication-assisted treatment (for both addiction and overdose). Only 4 percent of primary care physicians currently are DATA-certified. Less than half of treatment programs offer MAT, and only a third of opioid addicts at these programs receive it. Patients, the AAFP is arguing, need to learn too. Most people store opioids in plain sight, and 55 percent of addicts started with opioids gotten from family and friends. Take the average person who got opioids after their wisdom teeth were pulled, says Kominek: “How many of us still have some in our medicine cabinet?”
Doctors still face many challenges. “Evidence is” still, as the National Institutes of Health concluded in 2014, “insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain.” But they can’t wait for that evidence to turn up. Increasingly, doctors are instead using an unlikely arsenal of weapons: humble questionnaires, painstaking education and a centuries-old reliance on body fluids to track ailments.
Ian Graber-Stiehl, The Daily Dose, August 12, 2018
Doctors deploy a surprisingly low-tech tool kit agains opioids