Blood Levels for Steady State Opioid Concentration??

[drusso]

Our Center doesn't have much experience with doing this? It's not part of our risk management rubric. Are others doing this? Is it becoming a recognized quality standard or monitoring parameter?

Pain Physician. 2015 Mar-Apr;18(2):E157-61.
Blood testing in chronic pain management.
Deer TR1, Gunn J.
Author information

• 1Center for Pain Relief, Inc, Charleston, WV; Ethos Research & Development, Fairfield, OH.

Abstract
Blood testing is quickly becoming a useful laboratory tool for opioid prescribers who wish to document and assess patient tolerance, more objectively monitor patient safety, and evaluate patient compliance using information that is not available with traditional urine drug testing (UDT). Blood testing does not need to be performed as frequently as UDT but provides extremely valuable information which can be used to more accurately evaluate patient compliance and assist with interpreting blood toxicology results commonly used in impairment or overdose cases. This narrative review presents the current evidence supporting the use of blood testing within the chronic pain management setting. In addition, this review aims to introduce and discuss the role of routine blood testing within the chronic pain management setting. Blood testing for the purpose of documenting opioid tolerance is a relatively novel tool for pain physicians and as such this review is not intended to be a comprehensive or exhaustive review of the scientific or medical literature. Prescribers must also be aware that this type of laboratory testing need only be administered to chronic pain patients receiving daily opioid therapy. Patients taking infrequent, low dose, or as needed medications are not anticipated to benefit from this type of test. Based on the complexity of both achieving acceptable outcomes with opioid treatment and the legal and societal issues at hand, we feel that the addition of blood concentration levels will become the standard of care in the near future.
KEY WORDS:
Chronic pain, blood testing, opioids, opioid tolerance, patient compliance, opioid overdose.

---

Members don't see this ad.

 

[lobelsteve]

And what lab company or proprietary tests are they making money off of? Or is this a gateway to their patented genetic tests?

 

[emd123]

"Patients taking infrequent, low dose, or as needed medications are not anticipated to benefit from this type of test."

Good excuse to keep as many patients as possible on "infrequent, low dose, or as needed medication" so as to avoid having one more test to order and interpret, and to minimize total opiate MED prescribed in your practice, on the first place.

 

[101N]

Look no farther than the journal in which it was publised. Chrony review.

 

[lord_jeebus]

I actually reviewed a case this week where a doctor requested this testing and had an interesting peer to peer (I did not approve it). He says he has his own manuscript coming out shortly based on routine use of this testing in his large practice over the past 2-3 years. His arguments were basically those found in the paper. He also admitted to a case of his that ended in a large settlement after the family of a patient who overdosed and died sued him. He thinks that having baseline serum levels documented to compare with postmortem testing will somehow protect him if it happens again.

 

[drusso]

Is this accurate??

"In many settings, physicians teach of limiting dosing based on morphine equivalent dosages (MED), but there is seldom any discussion or understanding that the MED may not correlate to the circulating blood levels. This concept is easy to understand if you consider 2 patient vignettes. Patient 1 is an 84-year-old woman with severe scoliosis and multiple compression fractures who is on 100 MED. She weighs 90 pounds and she has both liver and renal disease. Her medication list includes oral agents to treat cholesterol, hypertension, and rheumatoid arthritis. Patient 2 is a 35-year-old man who suffers from pain secondary to failed back surgery syndrome and is on 100 MED. He weighs 240 pounds and has no other health issues and takes no medications. When considering these 2 patient scenarios, it is not surprising that a blood concentration may be very different in them despite the same MED."

 

[Ducttape]

after reading that article...

im still not convinced as to whether there is any clinical utility towards this. if a patient is tolerant, would one do a blood test to determine what? that their serum level was low, so they are a fast metabolizer, so you can significantly increase the dose? but what if that said individual diverted half their pills, thus obtaining a low level, and then encouraging said physician to prescribe twice as much?

anyways, if someone is tolerant, isnt the best plan to stop? what medication do we increase exponentially if there is drug failure? blood pressure meds? cholesterol meds?

one of the authors is an employee of http://www.ethos-labs.com/

ADDENDUM: after thinking this through, i see this potentially being a dangerous practice. using serum levels is treating just a number without any bearing on the actual clinical effects. steady state levels will do little to determine the actual amount of medication that a patient may be diverting. for example, the young man on no meds will have a lower blood concentration. this would encourage the physician to prescribe more medication to the young man? would we need this expensive test to determine this?

suppose the young man was diverting half his meds all the time. his blood level is low. he states he is tolerant. doctor writes higher dose to counteract tolerance. guy gets to sell more drugs.

suppose the test is on the older woman. levels are high. based on these levels, doctor reduces dosage so as to avoid accidental overdose, and patient has horrendous pain, necessitating significant escalation in pain behaviors and use of other medications.

suppose the older woman doesnt use it as much as she states. you rely on the blood levels, which show a "therapeutic" level. patient's pain gets worse, she takes the prescribed dose... and overdoses. the use of the blood levels in this case would lead to false belief that overdose was not possible at the supposed prescribed dose.

we monitor lithium, carbamazepine, valproate levels... but are we doing that for clinical efficacy or are we doing that to monitor for toxicity? we monitor BGs, HgA1C for diabetic medication - but this is the clinical effect, not the blood level.