office based urine drug testing toolkit for safer opioid prescribing · 2019. 4. 10. · 4/9/2019...

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OFFICE BASED URINE DRUG TESTING TOOLKIT FOR SAFER OPIOID PRESCRIBING Presented by:

Dr. Nancy Fitch + Dr. Megen Brunskill

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Disclosure Statement:

We have no actual or potential conflicts of interest in relation to this program/presentation.

Dr. Megen Brunskill and Dr. Nancy Fitch

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Our group…

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What do you think about urine drug screens in opioid prescription settings?• Quiz #1

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Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care

Pain (2014) 155: 2575-2582

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Prescribing chronic opioids:

Doctors and Patients in PainOpioids introduce several elements that can potentially lead to deterioration of the doctor-patient relationship

• understanding pain• patients feel that physicians don't understand their pain when they don't offer opioid

medications and if they have pain they have a "right to pain medications”

• understanding opioid medications• opioids - unwanted burden and ineffective solution

• fear of causing harm to patients (addiction, overdose, side effects)

• paternalistic relationship

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What we did

• Program started in 2014

• We have something that is working

• We want to empower others to do the same or similar

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National Guidelines 2017

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UDS in the 2017 guidelines

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• A baseline urine drug screen may be useful for patients currently receiving or being considered for a trial of opioids.


• Clinicians may repeat urine drug screening on an annual basis and more frequently if the patient is at elevated risk or in the presence of any aberrant drug- related behaviours.

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How well do physicians determine risk of opioid misuse?

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•Relying on aberrant behaviour observations detects less than half of patients who are misusing drugs (Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patient receiving long-term opioid therapy. Anesth Analg. 2003;97(4):1097-1102)

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• Approximately 30% of urine drug screening will demonstrate aberrant results, largely because of prescribed opioid non-detection and tetrahydrocannabinol.

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RESEARCH POSTER PRESENTATION DESIGN © 2015

www.PosterPresentations.com

The prevalence of opioid abuse has reached an epidemic level.National guidelines recommend safer opioid prescribing practices,including consideration of monitoring patients with urine drugscreening (UDS). There is little evidence supporting or refuting theuse of UDS in the context of chronic non-cancer pain (CNCP)patients. The Marathon Family Health Team (MFHT) hasimplemented a randomized UDS program, aimed at making theprescribing of opioids safer. This research project evaluated theefficacy of randomized UDS to detect and manage opioid misuseamongst patients with CNCP. Of the 77 patients prescribed opioidsfor CNCP and stratified as low-risk, 71.4% completed at least oneUDS during the 12-month study period. Of these, 80% completed atleast one random UDS (≤36 hours of notice), and 20% completedonly scheduled UDS. Overall, 66.4% of the UDS results wereexpected, 29.7% unexpected, and 3.9% equivocal. The physicians atMFHT took action for 58.8% of the aberrant results. By the end ofthe study period, UDS led directly to concrete management steps in15/77 patients (19.5%). Of the 77 patients, 4 were escalated to anaddiction program, 2 were tapered or discontinued from opioids,and 9 were escalated to a higher-risk monitoring system directly asa result of UDS. The results of this study show that in the primarycare setting, UDS can be effective for detecting and managingmisuse amongst low-risk CNCP patients being prescribed opioids.

ABSTRACT

BACKGROUND

PATIENT DEMOGRAPHICS

• The randomization program was effective in picking up aberrant(unexpected and equivocal) results:

– 61.8% of the aberrant results were detected through therandom selection process.

– 70.6% were detected through a short-notice appointment.

1. Efficacy of random UDS in a primary care setting 2. Comparison of different UDS methods

The rate at which CNCP patients are being prescribed opioidscontinues to increase.1–3 Addictions and prescription drug overdoseshave become a global epidemic.4 According to a recent report fromHarvard Medical School in the United States, opioid misuse and thenumber of opioid-related deaths is now comparable to deathscaused by smoking.5 The Public Health Agency of Canadareported that about 2,500 Canadians (865 from Ontario) died fromopioid overdoses in 2016.5,6 This number is much higher ascompared to the 728 opioid-related deaths in 2015 reported byOntario Public Health data.6

CONCLUSIONS

A combination of immunoassay and chromatography wasdetermined to be the best UDS test method as compared toeither of these tests used individually. Self-report was not ahelpful tool in detecting aberrant drug use in thispopulation.

ACKNOWLEDGMENTS

1. Northern Ontario School of Medicine, Lakehead University,Thunder Bay, ON

2. Marathon Family Health Team, Marathon, ON

3. Addiction and Chronic Pain Committee, Marathon FamilyHealth Team, Marathon, ON

The general objective of this study is to:

• Analyze whether random UDS, done by primary care providersin rural communities, is effective in detecting and managingmisuse amongst patients being prescribed opioids for CNCP.

The specific objectives of this study are to:

1. Analyze the efficacy of random UDS in a primary care setting.

2. Compare different methods of UDS.

3. Determine whether UDS results directly led to physician actionin managing opioid misuse.

1Medical Student, Northern Ontario School of Medicine , Lakehead University, Thunder Bay, ON2Family Physician, Marathon Family Health Team, Marathon, ON

Niharika Shahi1 and Dr. Ryan Patchett‐Marble2

The use of urine drug screening for safer opioid prescribing in chronic non‐cancer pain patients in rural Northern Ontario

RESEARCH OBJECTIVES

METHODOLOGY

• Physicians took action for 58.8% of the aberrant results.

Of the 77 patients in the program at the beginning of thestudy, 15 patients had UDS results that directly led to eitherescalation to an addiction program (4), tapering ordiscontinuing of opioid medication (2), or being escalated to ahigher-risk monitoring system (9).

• 55/77 patients provided at least one urine sample during the 12-month study period.

– 44/55 patients provided at least one random urine sample(patient notified ≤36 hours of appointment).

– 11/55 patients provided only scheduled urine sample(s)(patient had >36 hours of notice before appointment).

The project was approved by the Lakehead University ResearchEthics Board, as per Tri Council Policy Statement, as it involvescollecting data from human participants. No direct patient consentwas required as the project involves collecting secondary data frompatient chart reviews. Patient data collected from the MFHT EMRwas stored in password protected electronic files. The data collectedfrom patient chart reviews was analyzed using the SPSS software.

Male

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66%

Female26

34%

Gender

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Caucasian Indigenous

Number

of P

atients

Ethnicity

Male Female

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15

32

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26‐40 years 41‐55 years 56‐70 years 71 years and above

Number o

f Patients

Age Groups

Male Female

Fibromyalgia8%

Musculoskeletal Pain

80%

Neuropathic Pain

3%

Other9%

Pain Diagnosis

51.9 37.7 26.3 74.7 41.50

20

40

60

80

100

120

Fibromyalgia Musculoskeletal Pain

Neuropathic Pain Other AverageMorphine Eq

uivalent D

ose

(MEQ

) (m

g/d

ay)

Pain Diagnosis

Average Morphine Equivalent Dose

RESULTS

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3 1

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Randomized Non‐Randomized

Number o

f UDS

UDS Selection Process

Expected Unexpected Equivocal

• Of the total urine drug screens done:

– 76.2% were unscheduled (≤36 hours of notice).

– 23.8% were scheduled (>36 hours of notice).

• Chromatography and immunoassay, separately as well as incombination, were determined to be more effective at capturingaberrant results as compared to self-report.

– 25% of aberrant results detected by chromatographyalone.

– 28.6% detected by immunoassay alone.

– 46.4% detected by chromatography and immunoassay.

– Only 2/77 patients admitted to any non-prescribed drugsor medications on self-report.

Expected

66%

Unexpected

30%

Equivocal

4%

UDS Results

• Previous studies suggest that ~30% of UDS results will beaberrant, most of them due to cannabis and non-detection ofprescribed substances.9

• Cannabis in the urine was not considered an unexpected result inthis study. If it were considered unexpected, then the number ofaberrant results would increase significantly.

• Therefore, this study suggests higher rates of aberrant UDSresults in rural Northern Ontario compared to previouslypublished numbers in other populations.

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Male Female

Number o

f Patients

Aberrant Results by Gender

Unexpected Equivocal

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Caucasian Indigenous

Number o

f Patients

Aberrant Results by Ethnicity


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26‐40 years 41‐55 years 56‐70 years 71 years and above

Number o

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Aberrant Results by Age Group


No action41%

Increased monitoring26%

Suboxone or methadone for

addiction12%

Tapered dose3%

Warning

18%

Physician Action for Aberrant Results

3. Physician action

These results show that the random selection process for UDSis an effective method for detecting aberrant results in aprimary care setting.

MARATHON FAMILY HEALTH TEAM

The general objective of this study was to analyze the extent towhich systematic randomized UDS, in a primary care setting, canhelp detect and manage opioid misuse amongst CNCP patients inrural and remote communities of Northern Ontario. This study hadsome limitations as it had a small data set and no control populationto compare statistical significance of the results. The UDS programanalyzed in this study requires minimal resources and could bereplicated by other primary care teams.

Overall, this study suggests that randomized UDS in primary carecan lead to safer prescribing of opioids through identification of at-risk patients and subsequent escalation to addictions programs, ortighter monitoring and prescribing practices.

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Chromatography Alone Immunoassay Alone Chromatography & Immunoassay

Number o

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Screening Method for Aberrant Results

• Of the 3,913 patients at MFHT, 103 are prescribed opioids forchronic pain (>90 days duration), of which 97 are for non-cancer,non-palliative pain.

• Of the CNCP patients, 77 patients were stratified into the low-risk program, 7 into the high-risk program, 6 were excluded fromUDS for other reasons by their family physician (poor mobility,or receiving medications under observation in chronic care, etc.),and 7 patients should have been enrolled in the low-risk streambut were missed.

• 10% of all low-risk patients are randomly selected per month,through a computerized program, to complete UDS.

• Of the total urine drug screens done:

– 74% were initially selected through a randomizationprocess.

– 26% were “non-randomized” or physician-selected.

1Griggs C, Weiner S, Feldman J. Prescription Drug Monitoring Programs: Examining Limitations and Future Approaches. West J Emerg Med. 2015 Jan 1;16(1):67–70. 2Gugelmann HM, Perrone J. Can Prescription Drug Monitoring Programs Help Limit Opioid Abuse? JAMA. 2011 Nov 23 [cited 2017 Aug 31];306(20). Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2011.1712.3Kuehn BM. Opioid Prescriptions Soar. JAMA. 2007 Jan 17;297(3):249. 4Okie S. A Flood of Opioids, a Rising Tide of Deaths. N Engl J Med. 2010 Nov 18;363(21):1981–5. 5Chapin D. How to treat chronic pain without turning to opioids. The Globe and Mail. 2017 Jul 4 [cited 2017 Aug 31]; Available from: https://beta.theglobeandmail.com/life/health-and-fitness/health/how-to-treat-chronic-pain-without-turning-to-opioids/article35545093/?ref=http://www.theglobeandmail.com&.6Howlett K, Giovannetti J. Ontario invests $222-million to combat opioid crisis. The Globe and Mail. 2017 Aug 29 [cited 2017 Aug 31]; Available from: https://beta.theglobeandmail.com/news/national/ontario-invests-222-million-to-combat-opioid-crisis/article36113584/?ref=http://www.theglobeandmail.com&.7Canadian Centre on Substance Abuse. Prescription opioids. 2016 [cited 2017 Aug 31]. Available from: http://www.deslibris.ca/ID/248516.8Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. Can Med Assoc J. 2017 May 8;189(18):E659–66.

RESULTS

http://www.ahchealthenews.com/2016/05/06/naloxone-reverses-opioid-overdose-saves-lives/

http://www.cbc.ca/news/canada/toronto/harm-reduction-workers-open-letter-emergency-opioid-crisis-overdose-deaths-1.4264783

https://beta.theglobeandmail.com/news/national/ontario-invests-222-million-to-combat-opioid-crisis/article36113584/

Historically, higher rates of drug abuse have been seen in rural andremote communities of Northern Ontario as compared to the rest ofthe province.7 Several screening tools have been developed to detectopioid misuse and diversion. National guidelines for prescribingopioids for CNCP recommend considering UDS as one riskmitigation strategy.8 However, it is unknown to what extent UDS, ina primary care setting, can help detect and guide management ofopioid misuse.

9Turner JA, Saunders K, Shortreed SM, LeResche L, Riddell K, Rapp SE, et al. Chronic Opioid Therapy Urine Drug Testing in Primary Care: Prevalence and Predictors of Aberrant Results. J Gen Intern Med. 2014 Dec;29(12):1663–71.

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Results From Our Clinic

• 77 patients enrolled into the “low risk stream”

• 55/77 provided a random urine drug screen (71%)

• 30% were unexpected results• Previous studies state that 30% is expected to be aberrant results

but they included THC – we excluded THC so our results were higher than expected

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Caution from the guidelines

• Prescribers may implement risk mitigation strategies with the aim of reducing harm. However, there is also concern that prescribers adopting potentially ineffective risk mitigation strategies may become less vigilant about possible opioid-related harms, and more willing to prescribe opioids for chronic non-cancer pain.

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Results from Our Clinic

• 58% of the unexpected results led to action by the prescribing physician• escalation up the opioid ladder (43%)

• transition to addiction treatment (12%)

• taper and discontinuation of opioids (3%)

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• Formal study of urine drug screening for risk mitigation was limited to only one abstract report of a large retrospective cohort study that found no difference in rates of opioid overdose for those who did or did not receive baseline urine drug screening

• More studies are needed!!

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HARMS Program

• For more information about implementing a program like this please visit www.harmsprogram.ca

• High Yield Approach to Risk Mitigation and Safety

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Back to the Guidelines…

• When ordering a urine drug screen:• clinicians should ask patients about all medications/drugs recently

taken

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Start-IT

• Electronic tool for patient self-report and interpretation of urine drug screen results

• Allows for automatic entry of results into EMR

• For more information, check out www.harmsprogram.ca

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Back to the Guidelines…• When ordering a

urine drug screen:• clinicians should

ask patients about all medications/drugs recently taken

• be aware of local resources to assist them in assessing for potential false positive and false negative results

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Back to the Guidelines…

• When ordering a urine drug screen:• clinicians should ask patients about all medications/drugs recently

taken

• be aware of local resources to assist them in assessing for potential false positive and false negative results

• Consider the different options of urine drug screening and select the one that fits your practice best

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Let’s Practice Some UDS Interpretation

• Quiz 2

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Urine Drug Tests (UDT)

Urine Drug Tests (UDT)

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UDS Kits

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Multiple options for clinic point of care tests

We choose $4 5-item kits: (Hospital chooses $12 12-item kits.)

• EDDP (methadone metabolite)

• Morphine-based Opioids

• Oxycodone

• Benzo

• Cocaine

--you can get amphetamines, PCP, THC, etc

--you can get a separate fentanyl or buprenorphine dipstick for $1

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Urine Drug Test – opioids

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Immunoassay (IA)

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Advantages Disadvantages

fast (done in office) sensitive cheap (~$3-12 each,

however not covered by OHIP)

non-specific MOP (morphine-based

opioids) does not detect synthetic opioids such as fentanyl

the “BZO” doesn’t pick up clonazepam

Chromatography

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Advantages Disadvantages

specific (few false positives)

tests dozens of different drugs automatically

Expensive (covered by the province though)

Slow If you want certain drugs

(like mushrooms), then you have to specifically ask for them

Need to write ‘no lower limit ritalinic acid’ for methylphenidate

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Disadvantages of LC/MS

• The screen only picks up drugs they are looking for: immunoassay will be positive for a new drug in a class

but LC/MS has to be designed for the specific chemical;

we depend on Gamma Dynacare to monitor street uses and adapt test.

• While false positives do not happen at a chemical level with LC/MS, due to the requirement for technician entry, tech error is unfortunately a possible source of false positives

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Advantages of IA + LC/MS

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“the double method”

• Urine is dipped in the clinic setting in front of the patient to minimize patients claiming error (‘that wasn’t my sample’)

• This same urine sample is bagged and labeled in front of the patient and sent to the lab for provincially-covered LC/MS analysis (‘broad spectrum tox screen”)

• Unexpected results are then compared/reinforced by 2 results on the same urine

• Minimizes risks of physicians acting on false positive or false negative results

Disadvantages of the double method: • Cost• delay for LC/MS report

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Costs & Ordering

• Boxes of 100 kits

• Provincial supplier, arrive by mail

• Zero cost to us through cost recovery via local employers

clinic agrees to be the local facilitator for employer-required UDS at a cost per test to employers

All income from this service goes to UDS kit purchases; it is not a revenue generator

• UDT appt banks -- two 3h banks of appts each week have sufficed for our clinic (includes our suboxone program) – + funding for new staff !

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Let’s do some practice

• The following are real examples…notice how helpful having BOTH IA and LC/MS reports is...

• Also pay attention to how the patient self-report helps with interpretation of results

• Call out your synthesis that the UDT is ”expected” or “unexpected” once we reach the LC/MS of each

example

Example #1 (1 of 2)

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Example #1 (1 of 2)

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Example #1 (2 of 2)

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Example #2 (1 of 2)

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Example #2 (1 of 2)

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Example #2 (2 of 2)

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Example #3 (1 of 2)

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Example #3 (1 of 2)

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Example #3 (2 of 2)

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Urine Drug Screens (UDS)

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Example #4 (1 of 2)

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Example #4 (1 of 2)

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Example #4 (2 of 2)

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How do you add an opioid prescribing program to your practice?

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What we did…

• Use objective tools and strategies• Risk stratification of patients

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Opioid Risk Tool

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What we did…


• Treatment contracts

• Urine drug screening

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What we did…




• BPI

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BPI – Brief Pain Inventory72

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What we did…




• BPI

• Chronic Pain Flowsheet

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What we did…




• BPI


• Opioid Prescribing Ladder

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Our Program

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What we did…




• BPI



• Opioid Prescribing Program

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Our Program

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What we did…• Use objective tools and strategies

• Risk stratification of patients



• BPI



• Opioid Prescribing Program

While chronic pain is a subjective diagnosis, the use of objective tools during opioid therapy appears to ease much of the stress/burden to the prescriber.

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Lessons learned…

• Patient resistance• Use of a “universal precautions” approach

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Universal Precautions

Benefits of universal precautions for random urine drug screening in pain management:

facilitate appropriate use of opioid medications (Manubay JM, Comer SD, Sullivan MA. Treatment selection in substance abusers with pain. Adv Pain Manage. 2008;2(2):59-67)

mitigate diversion (Ives TJ, Chelminski PR, Hammett-Stabler CA, et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46)

reduce illicit drug use (Schiller MJ, Shumway M, Batki SL. Utility of routine drug screening in a psychiatric emergency setting. Psychiatr Serv. 2000;51(4):474-478) Also Manchikanti2004, Manchikanti 2006)

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Lessons learned…


• Advertise the program

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Lessons learned…


• Advertise the program

• Remember the goal is safety not punishment

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Lessons learned…

• Patient resistance

• Interpretation Issues• Get to know your local lab

• Use metabolism charts

• Self report is vital

• Remember time is your friend

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Lessons learned…


• Interpretation Issues

• Dealing with the Results• Conversations about abnormal results become easier because it is

an objective finding

• Explain the ladder to the patient and use it to create a plan

• Remember it is not meant to be a punishment – the focus is safety

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Our Program

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Lessons learned…


• Interpretation Issues

• Dealing with the Results

• System Issues• Creation of a master list

• Contact issues

• Which type of UDT should be used

• Record keeping

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Questions?

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http://[email protected] [email protected] [email protected]

Documents from the MFHT Opioid Prescribing Program (MOPP) Toolkit are

available by logging into MI OWL:

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miowl.org/owls/categories/1

MFHT ToolkitMFHT chronic pain flowsheet

MFHT addictions flowsheet

MFHT UDS protocol

MFHT UDS patient self report

MFHT UDS recording form

MFHT UDS agreement

BPI

MOPP/SOPP flowchart

MFHT chronic pain questionnaire

MFHT addictions questionnaire

MFHT opioid contract

MFHT low literacy opioid contract

SOPP opioid contract

SOPP low literacy opioid contract

MOPP patient handout

MFHT suboxone agreement

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HARMS Program

• For more information about implementing a program like this please visit www.harmsprogram.ca

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Example #5 (1 of 2)

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Example #5 (1 of 2)

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Example #5 (2 of 2)

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Example #6 (1 of 2)

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Example #6 (1 of 2)

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Example #6 (2 of 2)

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Example #7 (1 of 2)

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Example #7 (1 of 2)

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Example #7 (2 of 2)

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Example #8 (1 of 2)

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Example #8 (1 of 2)

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Example #8 (2 of 2)

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MFHT Opioid Prescribing Program

Note to workshop participants: you can make this yours, see the toolkit! Education for patients is key.

What is the MFHT Opioid Prescribing Program?

It is a framework for physicians and nurse practitioners who prescribe opioid medications to patients for

chronic non‐cancer pain. The program helps physicians to safely and effectively prescribe these

medications to patients.

How does an Opioid Prescribing Program help patient safety?

Having a clinic‐wide program for the use of these medications ensures that all patients have the same

quality and care. Specialists in chronic pain call this type of program “universal precautions”. It is much

the same as wearing gloves for procedures or washing hands between seeing patients. The focus of this

program is on physician practice and not individual patients in order to ensure safety for everyone.

Unfortunately, there has been a steady increase in opioid medication overdoses in Ontario and MFHT

wants to do our best to utilize these medications in the safest way possible. Studies show that using

urine drug screens can prevent opioid medication misuse.

What does this mean for me?

If you receive opioid medications for chronic pain you will be asked to sign an opioid contract which is an

agreement between you and your family physician. The contract explains the responsibilities of the

physician and the patient in using these medications. You will also complete a risk assessment to explore

your risk of developing an addiction to opioid medications. If you score “at risk” for addiction, it does

not necessarily mean that you won’t receive a prescription for opioid medications; it just means that

your physician will likely create a more structured way of dispensing these medications to keep you safe.

Finally, you will be asked to provide urine drug screens. The clinic has a computerized random urine drug

screening program. When your name is selected by the computer, you will be called by a staff person

and asked to provide a urine sample within 24 hours. If you are unable to come to this appointment

your family physician will be notified and will determine the next steps with you. Again, this doesn’t

mean that your prescription will be stopped, but it will likely result in a period of time of more frequent

urine drug screens. While coming in to provide urine drug screens can be an inconvenience, please

remember that ALL patients on these medications are being asked to do this. This is the best and safest

practice.

How do I get more information?

Please speak to your family doctor if you are on these medications to learn more about this program.

UDT immunoassay interpretation cheat sheet

SUBSTANCE Length of time detected

False Positive possibilities

False negative possibilities

BZO 2‐30 days Concentrated urine Clonazepam not detectable by immune; dilute urine

COC 2‐5 days Concnetrated urine Dilute urine

EDDP 1‐4 days Concentrated urine Dilute urine

MOP 2‐4 days Poppy seeds, quinolone antibx, DM cough product, gravol, concentrated urine

Synthetic opioids NOT detectable, eg fentanyl, oxycodone, suboxone;

dilute urine

OXY 1‐3 days concentrated urine Dilute urine

Broad Spectrum LC/MS cheat sheet

“broad spectrum tox screen” 1. The window for detection of opioid in urine is max 2‐4 days after last use. This varies from opioid to

opioid, and from patient to patient.

2. For their broad spectrum urine toxicology screen, Gamma Dynacare commits to updating the Liquid

chromatography/tandem mass spectrometry list of substances, based on reports of community use.

Tramadol remains pending. Currently, the following substance testing may not be non‐self‐explanatory

and are therefore mentioned here:

o 7‐aminoflunitrazepam, 7–aminonitrazepam = Rohypnol or ‘roofies’

o 6‐acetylmorphone = recent heroin use

o buprenorphine = suboxone; norbuprenorphine = suboxone metabolite

o cocaethylene = cocaine and ETOH use

o cotinine = nicotine metabolite

o des‐alkyl‐flurazepam = midazolam metabolite

o dihydrocodeine = new semi‐synthetic opiate; hydrocodone = Vicodin

o EDDP = methadone metabolite

o Levamisole = an antihelminth used to adulterate cocaine

o mCPP, MDMA = ecstasy

o MDPV = bath salts stimulant

o MDA, MDEA = psychadelics

o Methamphetamine = ADHD med Desoxyn

o Naloxone = Narcan

o Naltrexone = Revia

o Norcocaine, norcodeine, norfentanyl, etc etc = metabolites

o Nordiazepam is actually an active metabolite of diazepam, chlordiazepoxide/Librium,

and several other less‐used benzos

o Ritalinic acid = methylphenidate metabolite

o THCA = medication THC eg Marinol

3. Common normal metabolites (see schematic below):

o Morphine is metabolized to hydromorphone

o Codeine is metabolized to hydrocodone and morphine, and after several days, morphine

may be all that remains in the urine

o Hydrocodone is metabolized to hydromorphone

o Oxycodone is metabolized to oxymorphone.

4. False positives do not happen at a chemical level with LC/MS/MS. BUT due to the requirement for

tech entry, tech error is unfortunately a possible source of false positives.

www.miowl.org ‐‐ Find the toolkit below in this open source medical library.

These are Word documents you can amend for your own clinic use.

For more information about implementing a clinic‐based opioid prescribing

program as part of a prospective study, please visit www.harmsprogram.ca

Use the Risk Ladder to manage UDT results.