An Evaluation of the Clinical Tools Used to Monitor Illicit Methamphetamine Use Among Chronic Pain Patients: A Cross Sectional Retrospective Study.

Danielle R. Schalk, B.S.and Jamie L. Lewis, M.D. Hospital Pharmacy. 2023;58(6):621-627. doi:10.1177/00185787231174752

ABSTRACT:

Purpose: Illicit drug use continues to be a concern for adults on opioid therapy for chronic pain. Prescribers use tools such as urine screening and confirmatory testing with mass spectrometry to monitor adherence to chronic opioid therapy contracts. Design: A cross sectional retrospective study was conducted using electronic medical records. Methods: Data was analyzed from 6558 urine samples of adult outpatients receiving opioid therapy at an urban pain specialty clinic who consented to urine drug tests. Results: From October 18, 2021, to October 21, 2022, 569 were positive amphetamine with immunoassay testing. 310 (54%) of those samples were absent amphetamine with or without methamphetamine while 259 (45.5%) were true positive amphetamine proven by confirmation testing. Analysis of confirmatory testing results identified 281 samples positive for amphetamine with or without methamphetamine. 71 samples confirmed positive for methamphetamine with or without amphetamine. 37 (52.1%) of those methamphetamine samples screened positive for amphetamine and 34 (47.9%) samples screened negative for amphetamine. 48 of the methamphetamine samples were sent for chiral confirmation testing. 45 (93.8%) samples were positive for D-methamphetamine while 3 (6.2%) samples were positive for L-methamphetamine. Only 5 (11.1%) of the 45 patients whose samples were positive for d-methamphetamine reported the use of illicit drugs before their urine sample was tested. Discussion: Confirmatory testing with mass spectrometry can detect illicit drugs, such as methamphetamine, with high sensitivity and specificity and should be used with all samples given the low sensitivity of screening immunoassay. It is of utmost importance that opioid pain medicine prescribers know the many possible interpretations of these results so that they are equipped to make appropriate clinical decisions to ensure the safety of the patient, prescriber, and practice.

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Poppy Seeds Signal Limitations of Urine Drug Testing Protocols

Karlee De Monnin, B.S., Danielle Schalk, B.S., Jamie Lewis, M.D., Marian Wilson, Ph.D., M.P.H., R.N., PMGT-BC

ABSTRACT:

Appropriate care for patients with chronic pain is complex, requiring a thoughtful and holistic approach to pharmacologic intervention, as well as appropriate monitoring when opioids are employed as part of a multimodal regimen. The urine drug test has become an expected standard when longterm opioids are prescribed, but it should be remembered that this test is not intended to be punitive. It is ordered to promote patient safety (Dowell et al., 2022). Recent literature and events surrounding the effect of poppy seeds on urine drug test results have drawn attention to the risks of misinterpreting this test (Bloch, 2023; Lewis et al., 2021; Reisfield et al., 2023; Temple, 2023). Misinterpretation of urine drug tests creates a potential for unfounded accusations from health care workers toward patients, thus, undermining therapeutic relationships and intensifying stigma. Such circumstances may also preclude chances to offer patients needed interventions. Therefore, a valuable opportunity exists for nurses to mitigate untoward consequences by developing a robust understanding of urine drug testing, destigmatizing chronic pain and opioid use, advocating for patients, and enacting change at both an individual and a systems-level.

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Drug-Drug Interaction Between Orally Administered Hydrocodone-Acetaminophen and Inhalation of Cannabis Smoke: A Case Report

Ross Jason Bindler1 , Christy J. W. Watson1, Abram J. Lyons1, Lillian Skeiky1, Jamie Lewis2, Michael McDonell1, Philip Lazarus1, and Marian Wilson1

ABSTRACT:

Objective: To determine if a 2-day protocol measuring pharmacokinetic and pharmacodynamic characteristics can demonstrate drug-drug interactions when smoked cannabis is added to orally administered hydrocodone/acetaminophen combination products. Case Summary: A 51-year-old non-Hispanic white male with chronic pain diagnoses participated in a 2-day pilot protocol. The participant attended two 7-hour in-lab days where he received 10 blood draws each day and completed self-administered pain and anxiety surveys. For both days, the participant took his prescribed dose of hydrocodone/acetaminophen (1/2 tablet of 7.5 mg/325 mg combination product) with the addition of 1 smoked pre-rolled marijuana cigarette (labeled as 0.5 g; 22.17% Δ9-tetrahydrocannabinol; 0.12% cannabidiol) on Day 2. Blood specimens were analyzed using mass spectrometry to quantify the difference of plasma hydrocodone levels between Day 1 and Day 2.

Results: Compared to Day 1, lower levels of pain and anxiety were reported during Day 2 with the addition of cannabis to oral hydrocodone/acetaminophen. Day 2 pharmacokinetic analysis also revealed more rapid absorption and overall lower levels of hydrocodone in plasma. Discussion: Lower hydrocodone plasma levels in Day 2 may indicate cannabis’s effect on metabolism and reduce the risk of opioid toxicity. The quicker absorption rate of hydrocodone could explain lower pain and anxiety scores reported on the second day. Conclusion and Relevance: A 2-day protocol was able to capture differences across time in pharmacokinetic and pharmacodynamic measurements. Larger studies can be designed to better characterize the potential drug-drug interaction of cannabis and opioids.

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Program Evaluation of a Home Exercise Program for Chronic Back Pain in the Outpatient Setting

Xiang Jing, DNP and Jamie Lewis, MD

ABSTRACT:

Research indicates many different interventions are potentially therapeutic in managing chronic back pain. While home exercise programs may be cost-effective for individuals, little has been published on the subject of how best to combine functional and psychologic instruments to measure structured exercise programs in an outpatient setting. This DNP project conducted a program evaluation of a pilot project which reviewed the efficacy of a home exercise program for people with chronic back pain. The project was approved by a multi-disciplinary team at a private spine and pain specialty practice. Participants were recruited from patients at this practice, 14 of whom completed this three-month pilot project with no reported adverse events. The program measured participants’ exercise pattern changes, back functional improvement, and compliance to the change of routine through the use of three validated questionnaires: Fear-Avoidance Beliefs Questionnaires (FABQ), Low Back Pain Disability Questionnaire (OSWESTRY), Exercise Self Efficacy Scale (ESES). The program evaluation provided valuable information on how a HEP may further adapt these measurement tools to provide relevant data in a fast-paced outpatient pain management setting.

Interpreting Urine Drug Test Results in the Context of Chronic Opioid Analgesic Therapy and Poppy Seed Consumption

Citation: Jamie Lewis, MD,  Karlee De Monnin, BS,  Jonathan Smith, BS,  Evan Lewis, Marian Wilson, PhD, MPH, RN (12 March 2021). Pain Medicine, pnab082, https://doi.org/10.1093/pm/pnab082

Goalistics Chronic Pain Program

Northwest Spine and Pain Medicine partnered with Washington State University on a research program looking at efficacy of Goalistics Online Pain Program combined with health coaching at treating chronic pain. Validating the effectiveness of Goalistics Chronic Pain Program and other online modalities helps to increase the scope of treatment options readily available to those suffering from chronic pain.

Building Efficacy for Successful Opioid Tapering

It can be challenging to decrease or discontinue opioid pain medication. Northwest Spine and Pain Medicine partnered with Goalistics, LLC to evaluate a new tool to help patients who are undergoing medically supervised opioid tapering. The development and testing of the Building Efficacy for Successful Tapering (BEST) Program is funded by a grant from the National Institute on Drug Abuse. The online BEST Program was designed to:

• Teach pain patients about different methods of pain management that don’t involve pain medication

• Help them to build their own custom list of “pain reducers”

• Allow them to track and test the effectiveness of each method

• Identify the best strategies for them

Two studies were conducted. The first study is a review of the BEST program by patients who are currently undergoing opioid tapering. Their feedback will help ensure that the BEST Program is user-friendly and beneficial to future program users. The second study is a pilot randomized controlled trial to examine the efficacy of the program.

Cannabis use is related to self-efficacy but not sleep or pain symptoms: A survey of adults prescribed opioids for pain or opioid use disorders.

T. Bigand, M. Wilson, S. Riedy, J. Lewis (2017). Cannabis use is related to self-efficacy but not sleep or pain symptoms: A survey of adults prescribed opioids for pain or opioid use disorders [abstract]. The Journal of Pain. 12.121

Inadequate pain management and sleep difficulties are commonly reported by people using opioids to treat persistent pain or for medication-assisted treatment of Opioid Use Disorder (OUD). Cannabis use is frequently reported within both populations to manage pain and sleep problems, although how cannabis influences co-occurring symptoms is uncertain. Self-efficacy, the confidence that one can control symptoms, can improve pain and sleep symptoms. It remains unknown how cannabis use relates to self-efficacy in managing symptoms of pain and sleep. To explore relationships between cannabis use, sleep quality, pain intensity, and self-efficacy, survey data of adults prescribed opioids for OUD (n = 150) and persistent pain (n = 150) were analyzed. The Pittsburgh Sleep Quality Index (PSQI) global score and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity and self-efficacy subscale scores were used to assess sleep quality, pain intensity, and self-efficacy, respectively and a questionnaire assessed cannabis use. Data were analyzed using linear regression with main effects for sample (OUD and persistent pain) and cannabis use (yes/no) in the last month and their interaction. Overall, 87% of all surveyed adults had clinically relevant poor sleep quality (PSQI > 5). Better sleep quality was associated with greater self-efficacy (F1,225 = 23.30, P < .001) and less pain intensity (F1,230 = 29.95, P < .001). Cannabis use in the last month did not predict sleep quality or pain intensity (P > .70). Cannabis users had higher self-efficacy scores than non-users (F1,277 = 6.78, P = .01). Persistent pain patients had poorer sleep quality (F1,225 = 10.14, P = .001) and greater pain intensity (F1,281 = 32.43, P < .001) than OUD patients; self-efficacy did not differ (F1,277 = .27, P = .60). Evidence does not support cannabis for improving pain or sleep for either group, yet cannabis users have more confidence in symptom control. Future studies should focus on interventions that reduce symptom burden while enhancing self-efficacy.

Engagement in online pain self-management improves pain in adults on medication-assisted behavioral treatment for opioid use disorder

Citation: Marian Wilson, Myles Finlay, Michael Orr , Celestina Barbosa-Leiker, Naghmana Sherazi, Mary Lee A Roberts, Matthew Layton, John M Roll (2018). Engagement in online pain self-management improves pain in adults on medication-assisted behavioral treatment for opioid use disorders [abstract]. PubMed.gov Nov;86:130-137

Coaching to increase engagement in online pain self-management program

Citation: Bigand, T., Roberts. M., Lewis, J., Wilson, M. (2019). Coaching to increase engagement in online pain self-management program [abstract]. Pain Management Nursing, 20(2),96.