good info about opoid testing, regarding being dropped as a patient...

Discussion in 'Fibromyalgia Main Forum' started by sweetbeatlvr, Oct 31, 2008.

  1. sweetbeatlvr

    sweetbeatlvr New Member

    hi everyone. i found an interesting article online about opiate testing, and thought i'd pass it on.


    Lab testing of pain sufferers has become widespread because doctors have been forced into the role of drug diversion investigators. Surprisingly, when a doctor is prosecuted, the presence of a testing program is not taken as an indication that the doctor attempted to limit diversion; instead the details are nitpicked by ignoramuses, intent on demonstrating that the testing program was only "window dressing", intended to disguise the doctor's drug dealing behind a veneer of medical practice.

    Interpretation of test results, while it would seem to be straightforward, is actually anything but, and failure to do so competently often results in disaster for the legitimate patients who get tossed out. If not executed perfectly, the presence of a drug-testing program assists prosecuting attorneys in convicting the doctor they have targeted.

    Interpreting Laboratory Results
    Every result returning from the laboratory should be reviewed with skepticism regarding its accuracy, and each value should be interpreted in the context of the patient's entire clinical picture. Any lab value departing from the expected should receive scrutiny, with consideration of all of the possible pharmacological, metabolic, and laboratory variables that could have influenced the test.

    Quantitative variation
    Simply put, a lab value can be too low or too high. The key approach to sorting out this sort of thing is repetition of the test, with as much control over the circumstances as possible.

    Due to human and machine error, laboratories will produce a range of values, when repeatedly running exactly the same test. If a value looks too low or too high, the test should be repeated. Because of individual variation in absorbtion and metabolism of opioids it is impossible to know what a patient's blood level of a particular medication should be, without repeated testing. Levels are more meaningful when the patient is observed taking a dose of medication, usually about 1 hour prior to having his blood drawn.

    False negative and false positives
    In addition to being too high or too low, lab results can also be completely wrong. Urine testing for opiates is the situation in which this most commonly occurs in pain management. The test is fairly sensitive for opiates such as morphine, codeine, and heroin, but is not specifically designed to pick up the synthetic opioids, such as hydrocodone, oxycodone, and meperidine. The situation is further complicated by the fact that some of these substances are metabolized by some individuals into opiates that the urine screen does pick up. Other patients using synthetic opioids will consistently test negative for urine opiates.

    Many legitimate pain patients have been unfairly excluded from pain treatment because of a false negative on a urine drug screen for opiates. This situation also carries the risk of being used as evidence in a courtroom, that the doctor who continued to prescribe opioids to a patient after a negative urine opioid screen result returned, was knowingly contributing to drug diversion, by supplying a patient who wasn't taking his medication. This is not speculation; it is actually happening in courtrooms around the country.

    The only way to defuse the above accusation is by ordering blood opioid levels every time a urine drug screen is ordered.

    Certain opioids are not active in the form they are taken, and must be converted within the body to substances that effectively treat pain. Codeine and hydrocodone are the most notable examples. Codeine is converted primarily to morphine, and hydrocodone is converted to hydromorphone. Not every patient has the enzymes required to perform these metabolic conversions, and this has implications for what substances will be discovered upon testing.

    Metabolic Conversion
    A patient taking codeine can be expected to have both morphine and hydrocodone in his urine and blood, as a result of these conversions. As a consequence if an unexpected substance appears on testing, it is necessary to consider the metabolic pathways that may have produced it, prior to accusing the patient of stepping outside of the therapeutic relationship, and imposing sanctions against him.

    The body converts carisoprodol (Soma) to meprobamate. This is important to know, because carisoprodol is a common and effective neuromodulator, used in the treatment of chronic pain.

    The presence of any substance, other than what the doctor prescribed, or the absence of any substance he did prescribe, must be fully explained in the medical chart. Otherwise, this apparent failure will be offered in the courtroom as proof of drug diversion, which the treating physician criminally ignored. This sort of thing bolsters the prosecutor's contention that the doctor was nothing but a "drug dealer in a white coat".

    Urine Opioid Levels

    Urine opioid levels are almost worthless, because opioids tend to be concentrated in the urine. High urine opioid levels say more about the duration of treatment and concentration of the urine than they do about the dose of medication taken. They can produce confusing results, and in most cases, should not be ordered.

    Recommended Strategy
    In the current climate of regulatory oppression, the sane response is not to prescribe controlled substances, but if one must, here are some suggestions.

    Assume that prosecutors and their hired " experts" are malicious idiots, but don't underestimate them. They are good at what they do, and your conviction is their work product. It is also consistent with their drug war ideology, and a source income and power.
    Order blood levels for every drug prescribed, at the same time urine drug screens are obtained.
    Initiate a drug-testing program by ambush.
    Test regularly and often.
    Obtain blood levels every time a medication is titrated.
    Thoroughly document the analysis, decision-making process, and plan, regarding every result received, no matter how ordinary or expected it seems.

    Prosecuting attorneys have argued that positive blood and urine tests are worthless to detect diversion, because the patient was diverting all along, and only took their medication to pass the lab test. For this reason, it is necessary to initiate a testing program by ambush. Preferably the blood and urine are obtained in the office. A second option is to require the patient to go directly to the lab following their appointment.

    Results obtained in this fashion can be crosschecked by having the patient bring in their medications, so that they can be observed taking their prescribed dose. This is followed shortly by testing for blood levels.

    Blood and urine testing for opioids should be obtained for every patient, on a regular schedule. This should include urine testing for common drugs of abuse, and blood testing for every medication the doctor is prescribing, and the metabolites of each medication prescribed.

    Decision Making/Follow-up
    All decision making, and the resulting plan of action must be clearly documented in the medical record. Otherwise, it will be second-guessed by prosecuting attorneys, and the "experts" they hire to nitpick through every element of care. One must assume that the "expert" who will be reviewing the charts is completely ignorant about the meaning of lab test results, but that he will think he knows everything. These guys are dangerous
  2. Janalynn

    Janalynn New Member

    WOW - Great information. Thank you for sharing - especially in light of the recent posters who have been dropped by their doctors after "failed" urine tests. Everyone should print this and keep a copy in case needed.
  3. hermitlady

    hermitlady Member

    Are you sending a copy of this to your doc along with your letter you're writing? I'd get out my bright yellow highlighter and mark up the statements that could be relevant to your situation. Maybe we should all keep a copy of this in case we need it in the future!

    Thanks for more good info....Hermit
  4. sweetbeatlvr

    sweetbeatlvr New Member

    i'm planning on making a copy of this to take with me to my doctor.

    i'm gonna keep on researching to see what else i can find, and to also search the validity of this article, although it makes tons of sense with my situation.

    i tried to email the doctor who wrote this, but my email service could not deliver it? there's another email at the bottom of the page, when you go to the site, i may try that one.

    it's great information, for patients, and also for a prescribing doctor.

    my doctor knows me. i am surprised that she believes i would be capable of any wrong-doing with my meds. i'm hoping the info in this article will help her "look outside the box", and give me another chance!
  5. It's not only a SHAME, that WE, the people who are the *patients*, ill, in constant pain, worried about finances, etc the majority of the time, have now also had to become our OWN 'patient advocates', and 'case managers' meaning, that in order to NOT be just trampled on one way or another, (too MUCH medication, not ENOUGH medication, NOT taking it frequently enough, etc!), -- it is ALL set up, meant for us to FAIL.

    If you go in, knowing nothing, or little, you are 'ambushed' by doctors, like the foul, despicable DEMON, I was repeatedly insulted by, accused of everything under the SUN, except what my family & myself had ALREADY explained to him numerous times, that I was THERE for-- VOMITING, due to a collection of things, that all came together as a catalyst, provoking violent vomiting, rapid breathing, the worst dizziness, vision problems, etc.

    He WANTED to believe the worst, period.

    THEN- if you are MORE educated on YOUR OWN condition/treatment/medications, etc..... well, that just DOES NOT end well for you either, the majority of the time, THEN you must be a very 'familiar' user, an internet self-diagnose' addict, etc etc etc!

    It can never be simply the truth- that we have HAD to 'arm' ourselves, with all sorts of information, such as drug interactions, lab work abnormalities - and the various possible causes, metabolism rates and how THEY vary, and all sorts of stuff that pertain to our OWN bodies, and how THEY specifically, can and/or HAVE reacted, or FAILED to react to things in the past..

    No, they just will not believe that- no matter how sick you are, or have been in the past, how many doctors/specialists you've been to, seen, and picked up on THOSE doctors OWN WORDS, about YOUR CONDITIONS, they think you've just pulled that right out of thin air (the internet)...

    The article, I agree with, quite a bit, but, it is way beyond rediculous, already, how far we've all had to go, already, again- with 'arming' ourselves, with our "defense".. but, I Digress..... things just 'are the way the are' and that is that...

    However- in a 'perfect world', none of us would even have to GO through this-, and even if we DID- I agree, again- MOST labs, are unreliable, and definitely fluctuate, and also, that urine is probably MOST unreliable...

    BUT, we also all know, that U/A's are done, because they are cheapest, and there is no way, that insurance would pay for U/A AND Blood screening, at the same time, and certainly not for ANY repeats, and definitely no more than probably once a year, and for pain clinics only, at that... so, again... even if DOCTORS were on board, with, the advantage of protecting THEIR A##es as well... insurance, once again, would ultimately decide what gets done, who gets it done, how often, and all sorts of other catches. Even for the few people they MIGHT eventually agree upon having U/A & blood screens done concurrently, etc.. i'm sure, would be a VERY limited few, with massive documentation on some sort of problem (i.e. consistent, and very well documented history of some illness, disease, or genetic problem, that truly does cause some sort of gross metabolic change 'from the norm' (again- WHO decides "the norm" anyways!?)

    I wanted to add, also, through my own having to search the internet (at an ER nurses urging) to try and DEFEND myself, to my pain clinic NP, about ALCOHOL showing in my bloodwork (a trace amount)... being due to 'systemic candida' (the nurse is the one who took the time to help me try to figure out how the alcohol could have possibly showed up- the ER doctor flat out just didn't give a sh**, knowing he intended full & well on causing me immense trouble with my doctors, because, he and I argued, and even yelled, my entire miserable visit that night- and he could NOT take me correcting him on a very serious matter, concerning a potentially FATAL, genetic disease I was born with, and how it WAS NOT the same as another disease he had called it, among other issues we'd 'fought' over...)

    I came upon all sorts of articles, and even lawsuits, for mostly *police officers* and *firefighters*, who, of course, are randomly screened as well, and often- but, had wrongfully been fired, or suspended without pay- again- due to screenings- some of which, but definitely not limited to- COLD MEDICINES causing them to show "amphetamines"... and also some ASTHMA medications, again showing up as amphetamines, and even BENZODIAZIPENEs and the articles, job losses, lawsuits went on & on.

    I warned my sister immediately, about her inhalers, etc that she has to use for asthma, doubting that, if she encountered the same Doctor that I did, in the ER, that that knowledge would even matter... (in fact, she had to go there at 5am about a month ago- and I specifically informed the registration woman, that he was to come NOWHERE NEAR either of us- which worried my sister that I would cause trouble, just by having said that- I understand her concern- but also pointed out, that if she DID get HIM as her ER doctor- she would NOT get the help she needed anyways.. luckily, she did not, she got a GREAT doctor, I'd never seen before- and, even tho they called someone else in to see her- he still ordered a "CBC, & CMP" and, as I interrupted him and said "and.... testing for drugs & alcohol" he turned, and grinned at me, and just said "yes, we'll check for those too....." (almost like a "yeahhh, you get it... you must have been here before" ) least he was friendly..

    Anyways, thanks for your article,

    and your other post, btw, helped me out, as well, as, I too, thinking I had a good trusting relationship with my pain clinic NP, I've now realized, that, the past 3-4 appts they've asked me 'when was the last time you took your provigil" ? I thought they'd be fine with whatever date I told them, since I've always told them the whole 2 yrs the numerous reasons I use it so sparingly- but, only the last 3-4 appts, have they consistently asked me when I last took it, and NOW, I may* know "why"... and have told my sister to try & remind me, to take the bottle in there with me, from now on. *sigh*

    Take Care, Best wishes for you, with what you are going through, so sorry.
  6. sweetbeatlvr

    sweetbeatlvr New Member

    thankyou for your well thought, heartfelt response.

    i empathize with you, with all your troubles too.<3

    it is so very sad the way some people (us) are treated in the medical community. people who are very sick, whose lives have been stolen from them, who are trying to regain some form of normalcy. they (we) are being mistreated and shunned and laughed at by the very people who we need the help from the most.

    i never felt in a million years, when i got sick, that i would have a hard time getting help from medical community. little did i know, that i would have to fight to be heard and learn everything about my illness *by myself*! i know alot more now.

    it's been a rough road.

    i pray that we can all find some peace and comfort through our journey with this illness.<3