Presentation Transcript

1. 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
2. Do we have anything to disclose? Drs. Wheeler and Estes have no financial or personal relationships with commercial entities (or their competitors) to disclose.
3. Kathy Wheeler, PhD, APRN-FNP, NP-C, FAANP Assistant Professor, University of Kentucky UK Georgetown Family Practice
4. 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.
5. What is the history of drug screening? Military Business Medical
6. Why Urine? Less invasive Less costly Rapid results Available
7. 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
8. Anything else, ever? Serum Those for which antidotes exist and dosage needs to be calculated Digoxin Acetaminophen When correlating to clinical symptoms Ethanol Confirmatory Other
9. 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
10. What’s the story? Many agencies have created guidelines: Comprehensive initial evaluation Discussion of benefits and risks History and physical exam Look for signs-those at risk of unusual drug behavior PH alcohol or drug abuse FH alcohol or drug abuse Age 16-45 Preadolescent sexual abuse Hx of psychological disorders
11. What’s the story? Use formal addiction assessment tools Opioid 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
12. 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
13. What’s the story in kentucky? HB 1 in 2012 The pill mill bill Controlled substance use, drug abuse and diversion is epidemic in Kentucky Law required professional organizations to regulate prescribers of controlled substances KBML—urine drug screening mandatory KBN—urine drug screening recommended
14. What sort of testing is available? Immunoassay Class assays Analyte specific assays More sophisticated testing Gas chromatography (GC-MS) Liquid chromatography/tandem mass spectrometry (LC-MS/MS)
15. Any general recommendations? An extensive panel is needed An appropriate panel is needed Provider needs to communicate with the lab and know the issues
16. Any general recommendations? Immunoassay initially Positive results in above necessitate more sophisticated testing Appropriate collection techniques need to be applied
17. What are the issues? Medications/substances and relevant metabolites Analytical cutoffs Effects of metabolism Interpretation of quantitative values
18. What are the issues? Alcohol use Testing frequency Expected findings Unexpected findings
19. 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. ClinicaChimicaActa, 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
20. Jessica Estes, DNP, RN, MSN, APRN-NP Owner, Estes Behavioral Health, LLC
21. 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
22. What Do they do with abnormal results of a UDT? 92% talk with the patient 68% review the treatment agreement 6% change the opioid dose 3% change the opioid within the same class 30% could change to a non-opioid 26% would increase the frequency of patient visits 38% would increase the frequency of UDT 32% would engage additional providers 37% would discharge the patient 11% would report it to law enforcement
23. How confident do they feel to interpret results?
24. What was the score distribution?
25. Does increased confidence influence interpretation responses? There is no statistical significance between perceived confidence level and correct responses in interpretation
26. Does ordering urine drug testing correlate with increased ability to interpret?
27. Does ordering urine drug testing correlate with increased ability to interpret? 92% talk with the patient Chi-Square 1.5022 DF 1 Pr > Chi-Square 0.2203 There is not statistical significance between ordering UDT and interpretation of results correctly
28. What can be concluded from the data? Only 35% of the APRNs were able to answer more than 4 questions correctly Most 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
29. 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
30. What do they need to know? Commonly Used and Abused Drugs and Substances
31. Drugs of abuse? Alcoholis 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.
32. Drugs of abuse? Cocaineis 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.
33. Drugs of abuse? Heroinis 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.
34. 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)
35. But marijuana isn’t even addictive, and besides, everybody does it! 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.
36. 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.
37. 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)
38. 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)
39. 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
40. 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.)
41. So? This is anotherexample 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.
42. Comparison at a glance
43. 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 ChimActa, 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.
44. 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.