Q&A: ‘Incredibly cost-effective’ tool facilitates safer opioid prescribing
A physician practicing in a region hit hard by the opioid crisis helped develop a program that ascertains which patients in chronic pain who take opioids should undergo urine drug testing and how physicians can interpret these test results.
Ryan Patchett-Marble, MD, who practices medicine in rural northwestern Ontario, wrote in Annals of Family Medicine that he helped create the program to streamline the convoluted process for routine urine drug tests.
“We were aware of guideline recommendations supporting routine urine drug testing in chronic-pain patients, but like most North American physicians, we were not using it,” he wrote. “Our barriers were similar to those reported in the literature: confusion around which type(s) of testing to use and at what frequency; challenges around correct testing interpretation and how to act on the results; and physician time and human resource concerns.”
To overcome these obstacles, Patchett-Marble and his colleagues at Marathon Family Health developed High-Yield Approach to Risk Mitigation and Safety (HARMS), and within it, a Self-Report, Testing and Automated Reading Tool for Immunoassay Tests (START-IT). Patchett-Marble discussed the program and tool in an interview with Healio Primary Care.
Q: Tell us more about HARMS and START-IT.
A: HARMS supports routine urine drug testing as a method of monitoring safety in patients prescribed opioids for chronic noncancer pain. Its risk ladder guides prescribers in how often to require a patient undergo urine drug testing. It also shows prescribers how to act on the test results, regardless of what they are. By individualizing the monitoring frequency and prescribing interval to a patient’s level of risk — and adjusting that risk based on urine drug test results — prescribers can facilitate safer opioid prescribing in opioid maintenance therapy.
START-IT can help avoid the potentially serious consequences that can arise from the misinterpretation of urine drug test results. It collects the required information for an immunoassay test such as patient history, prescribed and nonprescribed medications/drugs and last ingestion and previous point-of-care test results, and then interprets them within the test’s limitations. It also gives customized interpretations/explanations of the test results, recommendations on when to send for confirmatory testing, and can even compile data for quality improvement and research purposes. START-IT synchronizes with our electronic medical records, but for those whose EMRs are not compatible, go to our website and copy and paste the interpretation into your own EMRs.
There are no fees to use either HARM or START-IT.
Q: How can HARMS and START-IT be implemented in primary care?
A: Ideally, prescribers would want to talk to their colleagues, both clinical and administrative, to educate them about these tools to make sure everyone is on the same page and willing to utilize the program consistently.
Next, a list of patients who would be included in the program should be created. These patients should be stratified from low- to high-risk. Appointment schedulers can then book patients for appointments, collect urine drug tests and track patient names and risk levels. A sample of a spreadsheet to help in this process can be downloaded from HARMS’ website. The website also provides an algorithm to guide appointment schedulers on what to do if a patient does not pick up the phone, cancels, is a no-show, etc., as well as a sample patient consent form and how to collect the urine drug test. All this said, use HARMS as a guide; improve the program for your unique clinic and patient population needs.
Busy prescribers only have to be involved with ascertaining a patient’s risk level for developing opioid addiction and interpreting the urine drug test result. If using the START-IT component of HARMS, the point-of-care test result will already be interpreted through automated algorithms.
Q: What barriers might be encountered when implementing this program? How can these barriers be overcome?
A: There may be some initial confusion among staff regarding what type of urine drug test to do and at what frequency, how to tailor frequency to patient risk level, how to avoid interpretation errors, how to act on results and how to do all of this while minimizing consumption of human and financial resources.
We also experienced some initial pushback from a few patients, but this was short-lived. The key to overcoming this barrier was having all of the prescribers on a similar page and being respectful of nonmedical staff so that they understand the reasons behind it.
In addition, we found that when it comes to educating other physicians about START-IT, the biggest challenge is that many prescribers view urine drug testing as a means to “catch” a patient who is addicted to opioids. It is important to understand that this is not the intent of START-IT or the urine drug test. The intent is to inform the risk-benefit balance of opioids and, when interpreted in the context of the whole clinical picture, test results may lead to important discussions that may change if and how opioids are prescribed and monitored. It is also important to note that studies have shown that physicians are not adept at interpreting urine drug tests which can lead to mistakes in patient management. Prescribers need to know where to go for more information.
Q: What modifications would be needed to implement the intervention in urban areas?
A: Urban centers may face challenges of having so many clinics that the disparity between a clinic that adopts HARMS and START-IT vs. one that does not is emphasized, whereas in a rural setting there is usually only one clinic that performs urine drug tests.
Q: What changes or modifications might be needed to implement this program and tool amid the current pandemic?
A: Like every clinical decision, weigh risks and benefits, keeping in mind that performing urine drug testing increases exposure for the patient and the health care professional administering the test.
Q: What data you can share regarding HARMS’ ability to identify more individuals at risk for opioid use disorder than those practices that do not use HARMS?
A: We published results in the Journal of Opioid Management last year on HARMS. We found that over a 12-month period, approximately one in five patients thought to be low risk for opioid addiction needed to change their treatment process. There were even some instances where addiction treatment was started.
Q: How cost-effective are these programs?
A: Though no formal financial analysis of these programs has been done, I can say that costs are minimal in the sense that most of the workload is absorbed by nonmedical staff. Therefore, you are not paying a physician or nurse practitioner to perform tasks below their level of training.
In addition, as previously mentioned, START-IT’s automated process only allows urine drugs tests to be sent off for confirmatory testing if a concern was identified on the cheaper point-of-care testing. In this sense, START-IT would be incredibly cost-effective because confirmatory testing can be expensive and therefore, clinics may not want to do it on every urine sample.
- HARMS. http://harmsprogram.ca/harms-program. Accessed December 11, 2020.
- Shahi N, Patchett-Marble R. J Opioid Manag. 2020;doi:10.5055/jom.2020.0581.
- START-IT. http://harmsprogram.ca/start-it Accessed December 11, 2020.