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Updated Guidelines from the Federation of State Medical Boards on Prescribing and Testing for Opioids

The Federation of State Medical Boards (FSMB) recommends that urine drug testing be used as part of a comprehensive management strategy for patients receiving prescription opioids for chronic pain.

“Periodic and unannounced drug testing (including chromatography) are useful in monitoring adherence to the treatment plan, as well as in detecting the use of non-prescribed drugs,” the authors state. “In drug testing in a pain practice, it is important to identify the specific drug and metabolites, not just the class of the drug.”

The FSMB is a national organization representing the 70 medical and osteopathic boards in the United States and its territories. The recommendations are included in “Guidelines for the Chronic Use of Opioid Analgesics,” an updated report released by the FSMB in April 2017, meant for use by state medical and osteopathic boards in setting their own guidelines for physicians.

Before prescribing

The decision to prescribe an opioid for chronic pain must be preceded by a thorough medical and family history, and documentation of “the presence of one or more recognized medical indications and absence of psychosocial contraindications for prescribing an opioid analgesic,” the authors say. Evaluation of the relative risk for substance use disorder (SUD), including the use of validated screening tools, “should be part of the initial evaluation.”

Patients with a history of SUD require special attention, which may involve consultation with an addiction specialist, before and potentially during opioid treatment. “Clinicians who treat patients with chronic pain are encouraged to also be knowledgeable about the identification and treatment of substance use disorder, including the role of replacement agonists such as methadone and buprenorphine,” they say.

Recommended additional elements of patient evaluation and risk stratification include:

  • Personal and family history of mental health disorders
  • Depression screening
  • Information from family members and/or significant others
  • Screening for obstructive sleep apnea
  • Diagnostic support from urine, blood, or other biological samples
  • Consultation with the state prescription drug monitoring program (PDMP)

Treatment planning and treatment agreement

In line with guidelines from the Centers for Disease Control and Prevention, the FSMB recommends a thorough discussion of risks and benefits of opioid treatment before beginning therapy. Written informed consent should be obtained. The FSMB report also recommends development of a Treatment Agreement. “Agreements outline the joint responsibilities of the clinician and patient, including the patient’s agreement to periodic and unannounced drug testing for opioids and other medications when deemed appropriate by the clinician,” they write, adding that the agreement should also include discussion with the patient about “how and when the PDMP will be reviewed as part of the patient’s care.”

The treatment agreement should include:

  • Treatment goals
  • Patient responsibility for safe medication use, storage, and disposal
  • Patient responsibility to obtain an opioid prescription from only one practice, and to have the prescription filled at only one pharmacy
  • Patient agreement to periodic drug testing
  • Clinician responsibility to respond to unforeseen problems and to prescribe scheduled refills

Periodic and unannounced drug testing

Drug testing is an integral part of opioid therapy for chronic pain, as outlined in the FSMB guidelines. “Drug testing is an important monitoring tool because self-reporting of medication use is not always reliable and behavioral observations may detect some problems but not others,” the authors state. “It is strongly recommended that patients being treated for addiction be tested as frequently as necessary to ensure therapeutic adherence, but for patients being treated for pain, clinical judgment trumps recommendations for frequency of testing.”

According to the guideline, forensic standards for collection and transport are generally unnecessary, but observed collection is preferred, especially in pain clinics. Initial testing may include class-specific immunoassay drug panels, most of which do not identify specific drugs. Drug-specific gas chromatography/mass spectroscopy testing can follow if necessary. Point-of-care immunoassay testing, has limitations, including high rates of false-positives and false-negatives, “such that point-of-care testing may not be appropriate for making definitive changes in medication management in populations at high risk for adverse outcomes until the results of confirmatory testing with more accurate methods…are obtained.”

When ordering drug tests, they note, “Clinicians need to be aware of the limitations of available tests (such as their limited sensitivity for many opioids) and take care to order tests appropriately. For example, when a drug test is ordered, it is important to specify that it include the opioid being prescribed.” They add, “because of the complexities involved in interpreting drug test results, it is advisable to confirm significant or unexpected results with the laboratory toxicologist or a clinical pathologist.”

View the complete guidelines here.

August 14, 2017