Debates in pain management testing

The annual healthcare costs associated with chronic pain are significant. Chronic pain also has important societal implications including the increasing availability of prescription narcotics. Recent literature and several professional societies have recommended urine drug testing to monitor adherence to prescription medications and to detect drug abuse and/or misuse. The technical benefits of urine drug testing using definitive testing methods such as LC-MS/MS are well documented. However, the guidelines, literature, and expert consensus on other aspects of pain management testing are sparse and/or more controversial. While many institutions and laboratories perform some form of validity and adulterant testing, the extent and utility of testing in pain management is not standardized. The benefits of point-of-care testing and the resources required to maintain a robust testing program are also not well studied. Furthermore, while urine testing is currently the gold standard in pain management, recent literature has shown some benefits of testing oral fluid and other matrices. There continue to be analytical and billing challenges with pain management testing. The utility of quantitative, definitive testing is controversial. Some laboratories only report qualitative results, while others find value in reporting some or all results quantitatively. Furthermore, the practice of laboratory professionals providing formal consultations for pain management testing and/or billing for interpretations is variable. Finally, pharmacogenomic testing is not routinely done in pain management, but some studies suggest it may be beneficial. Here we ask 7 individuals their expert opinion on different aspects of drug testing to assess compliance in pain management. Which validity and adulterant testing (e.g., observation of specimen collection, recording urine temperature immediately after collection, chain of custody, creatinine, specific gravity, pH, oxidants, nitrites) should be required? William Clarke: If there is a low suspicion for adulteration, measuring temperature, specific gravity, and creatinine should be sufficient. If tampering with the specimen …