MOVING FROM CHERRY AMES TO

NANCY DREW: SOLVING THE

MYSTERIES OF DRUG SCREENING IN

PRIMARY CARE

Kathy Wheeler, PhD, APRN-FNP, NP-C, FAANP

Assistant Professor, University of Kentucky

UK Georgetown Family Practice

Jessica Estes, DNP, RN, MSN, APRN-NP

Owner, Estes Behavioral Health, LLC

DO WE HAVE ANYTHING TO DISCLOSE?

Drs. Wheeler and Estes have no financial or personal relationships with commercial entities (or their competitors) to disclose.

Kathy Wheeler, PhD, APRN-FNP, NP-C, FAANP

Assistant Professor, University of Kentucky

UK Georgetown Family Practice

WHAT ARE THE OBJECTIVES?Describe the purpose, process and

complexity of drug screening for clinical decision making in primary care.

Discuss commonly used and misused drugs and substances, their metabolites and analytical cutoffs when evaluating patients in order to make clinical decisions.

Compare and contrast various drug screening tools, detailing advantages and disadvantages of use according to patient and clinical situation.

WHAT IS THE HISTORY OF DRUG SCREENING?

Military

Business

Medical

WHY URINE?Less invasive

Less costly

Rapid results

Available

WHY URINE?Easy to observe

Even point-of-care (POC) tests available

Consistent with the trend to look for drug use rather than confirm drug intoxication

Most development and research has focused on urinary drug metabolites and drug cut-off marks

ANYTHING ELSE, EVER?

SerumThose for which antidotes exist and

dosage needs to be calculatedDigoxinAcetaminophen

When correlating to clinical symptomsEthanol

Confirmatory

Other

WHAT’S THE STORY?White House Office of National Drug

Policy—Drug Abuse Prevention Plan April 2011

Increase prescription drug monitoring programs

Disposal of unused medications

Decrease pill mills

Support education of patients and providers

WHAT’S THE STORY?Many agencies have created

guidelines:

Comprehensive initial evaluationDiscussion of benefits and risksHistory and physical exam

Look for signs-those at risk of unusual drug behavior

PH alcohol or drug abuseFH alcohol or drug abuseAge 16-45Preadolescent sexual abuseHx of psychological disorders

WHAT’S THE STORY?

Use formal addiction assessment toolsOpioid Risk Tool (ORT)Screener and Opioid Assessment for

Patients with Pain-Revised (SOAPP-R)

Others

Emphasize the provider-patient relationship

Informed consent/contracts/agreements

Periodic assessment or when circumstances change

WHAT’S THE STORY?Use of various tools

Pill counts

Family/caretaker interviews

Communication with pharmacy

Prescription monitoring programs (KASPER)

Urine drug tests

Have a uniform practice policy

WHAT’S THE STORY IN KENTUCKY?

HB 1 in 2012The pill mill bill

Controlled substance use, drug abuse and diversion is epidemic in Kentucky

Law required professional organizations to regulate prescribers of controlled substancesKBML—urine drug screening

mandatoryKBN—urine drug screening

recommended

WHAT SORT OF TESTING IS AVAILABLE?

ImmunoassayClass assaysAnalyte specific assays

More sophisticated testingGas chromatography (GC-

MS)Liquid

chromatography/tandem mass spectrometry (LC-MS/MS)

ANY GENERAL RECOMMENDATIONS?

An extensive panel is needed

An appropriate panel is needed

Provider needs to communicate with the lab and know the issues

ANY GENERAL RECOMMENDATIONS?

Immunoassay initially

Positive results in above necessitate more sophisticated testing

Appropriate collection techniques need to be applied

WHAT ARE THE ISSUES?

Medications/substances and relevant metabolites

Analytical cutoffs

Effects of metabolism

Interpretation of quantitative values

WHAT ARE THE ISSUES?

Alcohol use

Testing frequency

Expected findings

Unexpected findings

REFERENCES? Chou, R., Fanciullo, G.J., Fine, P.G., Adler, J.A., Ballantyne, J.C., Davies,

P., . . . Miaskowski, C. (2009). Clinical guidelines for the use of chronic opioid therapy noncancer pain. Journal of Pain, 10, 113-130.

Hammett-Stabler, C.A., Pesce, A.J., & Cannon, D.J. (2002). Urine drug screening in the medical setting. Clinica Chimica Acta, 315, 125-135.

Heit, H.A. (2003). Use of urine toxicology tests in a chronic pain practice. In A.W. Graham, T.K. Schultz, M. Mayo-Smith, R.K Ries, & B.B. Wilford (Eds.), Principles of addiction medicine (pp. 1455-1456). Chevy Chase, MD: American Society of Addiction Medicine.

Heit, H.A., & Gourlay, D.I. (2004). Urine drug testing in pain medicine. Journal of Pain and Symptom Management, 27(3), 260-267.

Magnani, B., & Kwong, R. (2012). Urine drug testing for pain management. Clinical Lab Medicine, 32, 379-390.

Pesce, A., West, C., City, K.E., Stickland, J. (2012). Interpretation of urine drug testing in pain patients. Pain Medicine, 13, 868-885.

Peppin, J.F., Passik, S.D., Couto, J.E., Fine, P.G., Christo, P.J., Argoff, C., . . . Goldfarb, N.I. (2012). Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Medicine, 13, 886-896.

Standridge, J.B., Adams, S.M., & Zotos, A.P. (2010). Urine drug screening: A valuable office procedure. American Family Physician, 81(5), 635-640.

White House Office of National Drug Policy. (2012). 2011 prescription drug abuse prevention plan. Retrieved from http://www.whitehouse.gov/ondcp/

prescription-drug-abuse

Jessica Estes, DNP, RN, MSN, APRN-NP

Owner, Estes Behavioral Health, LLC

WHAT DOES THE KY DATA SHOW?

69% of the participants are ordering UDT

86% agreed with UDT as a clinical tool

65% have not attended any UDT continuing education in the last 5 years

45% Use Pill Counts in addition to UDT

69% Use Treatment Agreements in Addition to UDT

19% Never do UDT

WHAT DO THEY DO WITH ABNORMAL RESULTS OF A UDT?

92% talk with the patient68% review the treatment agreement6% change the opioid dose3% change the opioid within the same

class30% could change to a non-opioid26% would increase the frequency of

patient visits38% would increase the frequency of UDT32% would engage additional providers37% would discharge the patient11% would report it to law enforcement

HOW CONFIDENT DO THEY FEEL TO INTERPRET RESULTS?

WHAT WAS THE SCORE DISTRIBUTION?

DOES INCREASED CONFIDENCE INFLUENCE INTERPRETATION RESPONSES?

There is no statistical significance between perceived confidence level and correct responses in interpretation

DOES ORDERING URINE DRUG TESTING CORRELATE WITH INCREASED ABILITY TO INTERPRET?

DOES ORDERING URINE DRUG TESTING CORRELATE WITH INCREASED ABILITY TO INTERPRET?

92% talk with the patientChi-Square 1.5022DF 1Pr > Chi-Square 0.2203

There is not statistical significance between ordering UDT and interpretation of results correctly

WHAT CAN BE CONCLUDED FROM THE DATA?

Only 35% of the APRNs were able to answer more than 4 questions correctlyMost missed questions were related to

tylenol #3, methadone, and buprenorphine

None of the participants were able to answer all 9 questions correctly

No statistical difference between ratings of confidence and correct responses

WHAT ARE THE CLINICAL IMPLICATIONS?

Essentially – APRNs don’t have any idea what they don’t know about urine drug testing

Continuing education is needed to ensure competency – specifically related to drugs of abuse/misuse and UDT

As prescribing becomes more common, APRN programs need to place more emphasis on Urine Drug Testing

WHAT DO THEY NEED TO KNOW?

Commonly Used and Abused Drugs and Substances

DRUGS OF ABUSE?

Alcohol is a legal, addictive drug that depresses the central nervous system. Driving while intoxicated is illegal in all states in the US. Even after one drink (1 oz of hard liquor, 1 beer, 1 glass of wine), driving ability is impaired. Alcohol is cumulatively poisonous, and damages many organs of the body when used excessively (including the brain, liver, and heart). Chronic, heavy use of alcohol may lead to irreversible physical and neurological damage.

DRUGS OF ABUSE?

Cocaine is a strong central nervous system stimulant that affects the distribution of dopamine, a chemical messenger associated with pleasure. Dopamine part of the brain's reward system and helps create the high that comes with cocaine consumption. Cocaine usually looks like a white powder used for sniffing or snorting, injecting, and smoking (in the case of free-base and crack cocaine). In addition to the desired high, cocaine may produce feelings of restlessness, irritability, and anxiety, or even mania or psychosis.

DRUGS OF ABUSE?

Heroin is a very addictive drug processed from morphine, a substance extracted from the seedpod of the Asian poppy plant. Heroin produces a feeling of euphoria (a "rush") and often a warm flushing of the skin, dry mouth, and heavy feelings in the arms and legs. After the initial euphoria, the user may go into an alternately wakeful and drowsy state. Heroin is the second most frequent cause of drug-related deaths.

DRUGS OF ABUSE? Marijuana (weed, or cannabis) is one of the most

common drugs of abuse in Kenucky. Marijuana looks like a dry, shredded green/brown blend of flowers, stems, seeds, and leaves of a particular hemp plant. It usually is smoked as a cigarette, pipe, or in blunts, which are cigars that have been emptied of tobacco and refilled with marijuana. The main active chemical in marijuana is THC (delta-9-tetrahydrocannabinol), which quickly passes from the lungs into the bloodstream, and on to organs throughout the body, including the brain. Some of the short-term effects of marijuana use include problems with memory and learning; bizarre or distorted perceptions; difficulty in problem solving; loss of coordination; and increased heart rate.

A study has suggested that a user’s risk of heart attack more than quadruples in the first hour after smoking marijuana. (6)

Wrong on both counts, actually. But this illustrates the permission thoughts that serve to enable continued substance abuse. Permission thoughts (called “stinking thinking” in 12-step programs) make it “okay” for the individual to keep using, and you’re likely to encounter them if you ask a user about his or her habits.

But marijuana isn’t even addictive, and besides, everybody does it!

DRUGS OF ABUSE?Methamphetamine (“meth”) is made in

illegal laboratories and has a high potential for abuse and dependence. It is often taken orally, snuffed, or injected. Methamphetamine hydrochloride, clear crystals resembling ice, can be inhaled by smoking, and is referred to as "ice," "crystal," and "glass." Use of methamphetamine produces a fast euphoria, and often, fast addiction. Chronic, heavy use of methamphetamine can produce a psychotic disorder which is hard to tell apart from schizophrenia (methamphetamine induced psychosis). The drug also causes increased heart rate and irreversible damage to blood vessels.

DRUGS OF ABUSE?Ecstasy (MDMA) is the so-called “party

drug," It has both stimulant (like cocaine) and hallucinogenic (like LSD) effects. Ecstasy is neurotoxic (poisonous to brain cells), and in high doses it causes a steep increases in body temperature leading to muscle breakdown, and possible organ failure. Side effects may last for weeks after use, and including high blood pressure, faintness, confusion, depression, sleep problems, anxiety, and paranoia. (9)

DRUGS OF ABUSE?Acid (LSD) LSD, also called "acid," is sold

in the street in tablets, capsules, or even liquid form. It is clear and odorless, and is usually taken by mouth. Often LSD is added to pieces of absorbent paper divided into small decorated squares, each containing one dose. LSD is a hallucinogen and a very powerful mood-altering chemical. (10)

DRUGS OF ABUSE?Prescription drugs. Using a prescription

drug in a manner other than the intended prescription constitutes drug abuse. Some of the more commonly abused prescription drugs are:

Pain-relieving narcotics (Percodan, Codeine, Vicodin, Percocet)

Tranquilizers and sedatives (Halcion, Xanax, Ativan, Valium, BuSpar, Valium, Phenobarbital)

Muscle relaxants (Soma)Prescription amphetamines (Ritalin,

Cylert, Adderall)OxyContin

DRUGS OF ABUSE?

Over the counter drugs. Many different types of over-the-counter drugs and other substances can be abused. Just a few examples include:

Inhalants (paint thinners, nitrous oxide, model glue, magic marker fluid, spray paints, propane, butane, ect.)

Dramamine Mouthwashes Diet aids Cough and cold medications (especially those

containing DXM, like Drixoral Cough Liquid Caps, Robitussin AC, Dectuss, Phenergan, etc.)

SO?

This is another example of a permission thought. The distinction between “hard” and “soft” drugs is actually meaningless because ALL drugs of abuse can lead to the same consequence….addiction.

Once a person becomes addicted to ONE drug (marijuana, alcohol, prescription meds, heroin, etc.), he or she is as good as addicted to ALL drugs of abuse. For this reason, we train addicts for ABSTINENCE from all drugs of abuse.

COMPARISON AT A GLANCE

REFERENCES? Borack, J. I. (2002). An estimate of the impact of drug testing on the

deterrence of drug use. Military Psychology, 10(1), 17-25. Cipher, D. J., Hooker, R. S., & Guerra, P. (2006). Prescribing trends by

nurse practitioners and physician assistants in the United States. Journal of the American Academy of Nurse Practitioners, 18, 291-296.

Gourlay, D. L., Heit, H. A., & Caplan, Y. H. (2012). Urine Drug Testing in Clinical Practice. Baltimore, MD: Johns Hopkins University School of Medicine.

Hagemeier, N. E., Gray, J. A., & Pack, R. P. (2013). Prescription drug abuse: A comparison of prescriber and pharmacist perspectives. Substance Use & Misuse, 48, 761-768.

Hammett-Staber, C. A., Pesce, A. J., & Cannon, D. J. (2002). Urine Drug Screening in the Medical Setting. Clinical Chim Acta, 315, 125-135.

Kentucky Coalition of Nurse Practitioner and Nurse Midwives. (2010, 2011). Nurse practitioners and nurse midwives provide quality, cost effective care but barriers to their practice decrease patient access to care. Retrieved from http://www.kcnpnm.org/members/

Moeller, K., Lee, K. C., & Kissack, J. C. (2008, January). Urine drug screening: Practical guide for clinicians. Mayo Clinic Proceedings, 83(1), 66-76.

Morgan, P., De Oliveira, J. S., & Short, N. M. (2011). Physician assistants and nurse practitioners: A missing component in state workforce assessments. Journal of Interprofessional Care, 25, 252-257.

REFERENCES? Perrone, J., De Roos, F., Jayaraman, S., & Hollander, J. E. (2001). Drug

screening versus history in detection of substance abuse in ED psychiatric patients. American Journal of Emergency Medicine, 19, 49-51.

Pesce, A., & West, C. (2011). Drugs-of-abuse testing and therapeutic-drug monitoring. Medical Laboratory Observer, 42,44,46.

Pesce, A., West, C., City, K. E., & Strickland, J. (2012). Interpretation of urine drug testing in pain patients. Pain Medicine.

Reisfield, G. M., Webb, F. J., Bertholf, R. L., Sloan, P. A., & Wilson, G. R. (2007, November/December). Family physicians’ proficiency in urine drug test interpretation. Journal of Opioid Management, 3(6), 333-337.

Starrels, J. L., Fox, A. D., Kunins, H. V., & Cunningham, C. O. (2012). They don’t know what they don’t know: Internal medicine residents’ knowledge and confidence in urine drug test interpretation for patients with chronic pain. Journal of General Intermal Medicine, 27(11), 1521-7.