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Drug Mixing: The Most Prevalent, and Dangerous, Form of Drug Misuse

Is your patient mixing prescribed medications with non-prescribed or illicit drugs? Most clinicians underestimate the likelihood that their patients are engaging in this most-prevalent type of prescription drug misuse. But what they don’t know could hurt their patients.

According to the 2019 Quest Diagnostics Health Trends Report, 24% of patient test results, or nearly 1 in 4, show signs of drug mixing.

The annual Health Trends Report includes analysis of more than 4.4 million deidentified aggregated clinical drug monitoring tests performed by Quest Diagnostics for patients from all 50 states and the District of Columbia from 2011 through 2018. The report also incorporates findings from a survey conducted by The Harris Poll, commissioned by Quest Diagnostics and Center on Addiction, of 500 primary care physicians in the United States.

Clinicians can sometimes detect the signs of drug mixing at the office visit, according to Jeffrey Gudin, MD, Senior Medical Advisor, Drug Monitoring & Toxicology at Quest Diagnostics. In some cases, he says, the signs of mixing can be as obvious as somnolence, sedation, slurred speech, and reddened eyes. “In those cases, we can intervene with the patient right there. The more dangerous cases are those we don’t see in the clinic.”

In some cases, the patient is combining non-prescribed or illicit substances to increase the euphoria of the pain medication. In other cases, a patient is simply trying to sleep better, and doesn’t realize the danger of taking an additional medication. “I have reviewed many cases of people with upper respiratory tract infections who just want to get a good night’s sleep, who die from respiratory failure brought on by taking an extra pain pill, or by adding alcohol, or cough medicine, or a muscle relaxant, or an antihistamine. There is a very narrow window there. Combining opiates with alcohol or benzodiazepines is just a lethal combination,” he adds.

“The only objective way a prescriber knows what their patient is taking is drug testing. Everything else is subjective,” Dr. Gudin emphasizes. The Centers for Disease Control and Prevention recommend testing for patients on controlled substances at least annually, “but once a year is clearly not enough,” he adds.

Testing can improve the therapeutic relationship by setting the stage for important conversations. When the test result shows evidence of drug mixing, the patient needs to understand the seriousness of the risk, Dr. Gudin says. “I remind them that they signed a contract, to only take the medications we have prescribed. I explain that the test results indicate a dangerous combination, and that people can die from that. And then I tell them, ‘This is your one and only warning. If you want to be on pain medication from this office, you can no longer take that other medication, even once.’ That is a potentially life-saving conversation.”

For patients testing positive for an illicit substance, and when it appears it may be more-than-a-one-time event, a change in the treatment plan may be warranted. “If the patient remains in the practice after testing positive for an illicit drug such as cocaine, we will try to structure a high-risk regimen, with an increased frequency of testing. We use testing to confirm compliance with the treatment plan, and to alert us to problems for which we need to intervene, in order to keep the patient safe.”

The full 2019 Health Trends report is available HERE.