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Specialty Pharmacy Continuum • November/December 2021
CLINICAL
Drug Testing Gap Spurs a Different COVID Crisis In addition to the millions of lives claimed by COVID-19, another group of victims has emerged: the users and abusers of prescription and illicit drugs alike, who—as a potential result of decreased drug testing during the pandemic—have seen their overdose rates skyrocket. In a presentation during the 2021 virtual annual meeting of the American Academy of Pain Medicine, Jeffrey Gudin, MD, a faculty member in the Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami Miller School of Medicine, discussed this worsening crisis within the pandemic, along with strategies for mitigating its effects. “When the stay-in-place orders were enacted in March 2020, the AMA [American Medical Association] and CDC recommended that certain nonessential medical services be paused or halted,” Dr. Gudin said. “Unfortunately, drug testing fell into that category. But prescriptions didn’t stop, patients in pain didn’t stop, and drug abuse on the streets didn’t stop. So, we decided to compare our data from a period prior to COVID-19 to what happened during the first six or eight weeks of the pandemic.” To do so, Dr. Gudin and his colleagues used de-identified drug monitoring test results from patients tested at a large national laboratory (Quest Diagnostics) between Jan. 1, 2019, and May 16, 2020. Only those specimens with clinicianprovided prescribed drug information were included; this information indicates whether the prescribed drugs specified by the ordering provider—as well as other drugs—are detected in a specimen. The researchers compared results from Jan. 1, 2019, to March 14, 2020 (control) with those from March 15 to May 16, 2020 (during COVID-19). Positivity for unprescribed drugs was defined as the presence of a positive result for unprescribed or illicit drugs on urine drug testing. Similarly, drug misuse was defined as unprescribed drug positivity and/or noncompliance, such as the absence of a prescribed drug or the presence of an unprescribed or illicit drug. More than 800,000 drug tests were performed during the baseline control period, compared with almost 50,000 during the pandemic. Not surprisingly, clinical drug monitoring declined rapidly during the COVID-19 period. “I was amazed how much clinical drug monitoring declined rapidly during the pandemic, yet the most startling finding was how much the pandemic worsened the overdose and fentanyl abuse crisis,” Dr. Gudin said in an interview. Indeed, positivity for unprescribed fentanyl increased by 35% during the
pandemic compared with baseline (P<0.01). This finding, Dr. Gudin said, was more pronounced among men (5.7% baseline positivity, 8.6% COVID-19) than women (3.2% and 3.7%, respectively). Of note, the study also found that combinations of unprescribed fentanyl in patients who tested positive for other drugs also increased significantly in a number of cases. “This suggests that people are using dangerous drug
combinations whether they know it or not, as our street drugs are often laced with these synthetic opioids, such as fentanyl,” Dr. Gudin said. “Our study supports other recent findings that during times of crisis, drug misuse goes up,” he added. “So, although I understand the need to protect health care workers from COVID-19 exposure, it seemed like a bad time to recommend a pause in drug testing.” Given these increases in illicit drug use, the researchers recommended that clinicians reestablish opioid risk management strategies, including inperson visits, querying prescription drug monitoring programs (PDMPs) and interval drug testing. “Health care providers need to know
that now is the time to tighten the reins when treating those at risk, rather than continuing blindly from a risk management standpoint,” Dr. Gudin said. “With that in mind, every patient needs to have their PDMP checked, and every patient needs to continue to undergo drug testing, especially if they’re higherrisk patients,” he continued. “As we get back to face-to-face office visits, I think it will a bit easier to put our fingers on the pulse, figuratively and literally, to get a good handle on what’s going on in somebody’s life rather than an abbreviated telemedicine visit.”
Another Risk Management Gap: Opioid Use After Hospitalization
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f hospitalized patients who filled one or more opioid prescriptions within three months after discharge, roughly 15% had an opioid-related emergency department visit, a hospital readmission or death within one year of original discharge, a new study has found. The ad hoc cohort study (JAMA Netw Open 2021;4[5]:e218782) included 1,511 patients without a history of methadone or buprenorphine use who were enrolled in a randomized trial of medication reconciliation at McGill University Health Centre, in Montreal, between October 2014 and November 2016. Patients were followed for 12 months after discharge. Of patients with at least one post-discharge filled opioid script, 15.9% (n=41) had an opioid-related emergency department visit, a hospital readmission or death. Patients also had a 2.56-fold increased risk for opioid-related adverse events related to a cumulative use duration of more than 90 days compared with one to 30 days. Furthermore, there was a 3.51-fold increased risk with a mean daily dose higher than 90 morphine milligram equivalent (MME) versus 90 MME or lower. The results underscore that more frequent clinical vigilance and better pain treatment strategies are needed for patients taking opioids, according to study senior author Siyana Kurteva, BSc, a PhD candidate at McGill. “Policies to reduce extended opioid duration and its associated risk of potentially avoidable adverse health care events also need to be adopted,” Ms. Kurteva said. Charles E. Argoff, MD, the director of the Comprehensive Pain Center and director of the pain management fellowship at Albany Medical Center, in New York, said the results of the study are consistent in general with other reported findings. In addition, the CDC guideline for chronic opioid therapy notes “the increased likelihood of adverse effects with higher doses; hence the reason why there is a recommendation about MME dosing.” What is missing from the analysis, though, is the benefit that the study population derived from opioids, Dr. Argoff noted. “This omission is a serious weakness of the study. The analysis fails to inform a prescriber on how to optimize the benefit of opioid therapy while minimizing the harm.”
What About Nonopioid Pain Relief? Other pain experts suggest that rather than optimizing opioid therapy, a safer approach would be to maximize nonopioid pain modalities, particularly in surgical settings, which pose a high risk for opioid misuse and abuse after discharge. Numerous opioid-free analgesic options are available, and they have changed little in recent years, noted Eugene R. Viscusi, MD, a professor of anesthesiology at Thomas Jefferson University, in Philadelphia, and the immediate past president of the American Society of Regional Anesthesia and Pain Medicine. In the preoperative period, they include 400 mg of celecoxib or other nonsteroidal anti-inflammatory drugs, 1 to 2 g of acetaminophen, and/or 75 to 150 mg of pregabalin or 600 to 1,200 mg of gabapentin. Intraoperative nonopioid approaches include use of regional anesthesia, epidural analgesia and truncal blocks. Wound infiltration with local anesthetic also can play an important intraoperative role, he noted.
A Pharmacist’s Perspective Jeffrey Fudin, PharmD, was not surprised by the findings. “It was a mistake to think that drug testing is a nonessential item,” commented Dr. Fudin, the CEO and founder of Remitigate Therapeutics, in Delmar, N.Y. “Comparatively, it would not be acceptable to adjust diabetic medications or anticoagulant therapies without proper blood work. Why would we treat such a fragile and isolated population any differently? “Perhaps, on the one hand, regulators felt they were helping to lessen the burden on chronic pain patients, and that’s commendable,” he said. “Nevertheless, the poor outcome here should have been predictable.” Dr. Fudin offered suggestions for future similar situations. “Moving forward, it would be smart to include a team of pain experts on the government pandemic team to help government agencies develop pandemic policies regarding drug testing,” he said. Those policies “should be based on validated tools that stratify risk for drug abuse and misuse, rather than having a blanket rule that these are nonessential for all patients.” —Michael Vlessides
—Bob Kronemyer and Mike Vlessides
Dr. Kurteva reported no relevant financial relationships. Dr. Viscusi reported financial relationships with Esteve, Heron Therapeutics, Innocoll Pharmaceuticals, Merck, Salix Pharmaceuticals and Trevena Inc.
Dr. Fudin reported no relevant financial disclosures. Dr. Gudin reported a financial relationship with Quest Diagnostics, which offers drug monitoring services.
