Urine drug monitoring (UDM) has become an important risk mitigation tool for treating patients receiving long-term opioid therapy (LTOT). Several opioid prescribing guidelines recommend UDM as a standard of care for patients with chronic non-cancer pain for whom LTOT is necessary.1-5 Most guidelines do not specify which tests should be included in such screens, but the standard of care is initial and ongoing monitoring to ensure medication safety and to mitigate risks for opioid-induced respiratory depression.
Opioid-induced respiratory depression is a major concern when patients receive opioid therapy. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Drug Abuse Warning Network (DAWN), in 2010, there were 438,718 emergency department (ED) visits related to opioid pain relievers and 408,021 ED visits related to benzodiazepine abuse, alone or in combination with other drugs.6 An estimated 81,365 (18.5%) of the opioid pain reliever ED visits involved alcohol, and an estimated 111,165 (27.2%) of the benzodiazepine ED visits involved alcohol. Of the 3,883 deaths linked to opioid pain relievers, 860 (22.1%) involved alcohol. Of the 1,512 deaths related to benzodiazepines, 324 (21.4%) involved alcohol.6
Alcohol was also involved in a number of opioid overdoses in the largest prospective, observational US cohort study, published in 2010 by Dasgupta et al.7 They found that 2,182,374 patients were prescribed opioid analgesics, and 80% of those also were prescribed a benzodiazepine.7 There were 629 deaths involving opioid analgesics, and alcohol was involved in 12.2% of the overdoses involving opioid analgesics.7
These statistics support initial and ongoing monitoring of alcohol use together with the routine UDM, which for most Veterans Affairs (VA) hospitals includes at least “opiates,” methadone, amphetamines, barbiturates, phencyclidine, cocaine, and cannabinoids. Of note, the Washington State Agency Medical Directors’ Group, which has been at the forefront of opioid monitoring, released guidelines on prescribing opioids for pain, which consists of initial and ongoing UDM, including alcohol monitoring by ethyl glucuronide (EG) at least annually for all patients.8
Alcohol Monitoring Project
As part of a quality assurance project related to opioid use at the Samuel S. Stratton VA Medical Center, in Albany, New York, alcohol monitoring by EG was routinely done for all patients who received LTOT and who were monitored and/or seen in the pharmacy pain clinic.
The primary objective of this project was to assess how often EG is ordered, to enhance patient safety, and to minimize opioid morbidity and mortality by employing alcohol monitoring with EG. Secondary objectives were to provide recommendations to healthcare providers and education to patients on the risk of opioid-induced respiratory depression.
All non-cancer patients followed by the pharmacy pain clinic from June 2016 to September 2016 who received LTOT (≥ 3 months) plus or minus a benzodiazepine were screened and included in the study. Patients were identified electronically using the Tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). All opioids were included except for buprenorphine, tramadol, butorphanol, and pentazocine. The Institutional Review Board at the Samuel S. Stratton VA Medical Center reviewed this project and granted it an exemption in July 2016.
Prior to employing alcohol monitoring by EG, the investigators performed a retrospective chart review to assess how often EG was ordered within the past year for patients who met inclusion criteria. Patients were notified by the pharmacy pain clinic to report to the lab for routine monitoring. Laboratory findings and recommendations were entered in the computerized patient record system (CPRS) (Figure 1). Recommendations included alcohol counseling, reduction or elimination of LTOT and other sedative-hypnotic drugs, risk mitigation strategies, and support for routine alcohol testing.
Data were collected on patient demographics; comorbidities, including mental health disorders, substance use disorders, sleep apnea, alcohol dependence; opioid formulation types; active prescriptions for benzodiazepines; active prescriptions for in-home naloxone; in-date opioid-consent forms; UDM frequency; prescription monitoring program reports; and, ,Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) score.9
Fifty-six patients were identified by a QA screen and included in this project. The baseline characteristics are summarized in Table 1. Patient characteristics were consistent with a VA population, as it was mainly elderly men. The average morphine equivalent daily dose was 94 mg using the Practical Pain Management opioid calculator.10
Prior to employing alcohol monitoring by EG, 96% of patients had no previous EG screen, and the 4% of patients who were screened were positive for EG (Figure 2). After implementation of the QA program, 8.9% of patients were positive for EG, 44.6% were negative, and 46.4% did not show up to the lab for testing (Figure 3).
All of the patients testing positive for EG received alcohol cessation counseling of which 41% reduced or discontinued their opioid use. Risk-mitigation interventions included updating consent forms for long-term opioid use for 7 patients and naloxone prescriptions for 6 patients. Pharmacy-led interventions were highly accepted among providers. All interventions and acceptance are documented in (Table 2).
Alcohol consumption plays a significant role in opioid and benzodiazepine overdose and death. Concomitant use of alcohol, opioids, and/or benzodiazepines increases the risk for opioid-induced respiratory depression and overdoses. This project found that 1 out of every 11 patients (9%) who were taking chronic opioid therapy tested positive for EG. The authors concluded/˘ that this number may be even higher given that approximately 46% of patients did not report to the lab.
Interventions such as alcohol counseling and the offer of safer therapeutic options could be employed when clinicians are alerted to comorbid alcohol use among chronic pain patients. Additionally, this project identified patients at high risk for opioid-induced respiratory depression and provided prophylactic in-home naloxone prescriptions with appropriate counseling.
There were several strengths and limitations of this project. The patient demographics were consistent with a VA population. Veterans are twice as likely to die from an accidental overdose and enter substance abuse treatment for alcohol than non-veterans. Thus, this project examined a relevant high-risk patient population and promoted provider awareness and education about alcohol monitoring.
Limitations included a short time span, thus leading to a small sample size, and relying on the patients to report to the lab, which was challenging, especially if they didn’t want their providers to know they were drinking alcohol while taking opioids.
This project identified patients ingesting alcohol in combination with long-term opioid therapy with or without benzodiazepines who previously reported no alcohol use. Approximately 9% of patients were found to be EG positive while taking prescribed opioids. These preliminary outcomes support initial and ongoing alcohol use monitoring.