Use of drug testing to treat substance abuse and pain in primary care.

The treatment of chronic non-malignant pain with opiates in patients with active substance abuse is controversial. We tend to see practices where the pain is under treated because of the substance abuse or the pain is treated and the substance abuse is under treated. Pain is best controlled when both pain and substance abuse are maximally treated. Approximately 33% of our patients with chronic non-malignant pain seeking controlled substances tested positive for marijuana, cocaine, alcohol, or combinations. Patients testing positive were referred to a substance abuse counselor. Very few patients were compliant with the referral. This created a need for a different approach. We started a nurse lead opiate renewal clinic within our primary care team for patients with chronic nonmalignant pain on opiates. The clinic is almost 1 year old, and meets weekly for 2 hours. Twenty-five patients are seen in a group setting. Patients are drug-tested at each visit. Positive drug tests are followed weekly with weaning of opiates if repeatedly positive. Negative drug screens are followed at 4 to 8 week intervals. Sixty-four (29%) patients tested positive for marijuana, cocaine, or a combination. After drug testing was started 26 (41%) were able to stop. Thirty-eight (59%) were not. There were 44 patients who used marijuana only, 20 (46%) stopped. There were 8 patients who used cocaine only, 3 (38%) stopped. There were 12 patients users of cocaine and marijuana, 3 (25%) stopped. Our results show that weekly-to-monthly follow-up with drug testing and limiting renewals may be a successful way to control substance abuse and improve the lives of patients with pain.

Jerome M. Sampson, MD, MSA, CPE. Primary Care (PC-5), VA Medical Center, Gainesville, FL.