Urine drug testing: current recommendations and best practices

BACKGROUND

The precise role of urine drug testing (UDT) in the practice of pain medicine is currently being defined. Confusion exists as to best practices, and even to what constitutes standard of care. A member survey by our state pain society revealed variability in practice and a lack of consensus.

OBJECTIVE

The authors sought to further clarify the importance of routine UDT as an important part of an overall treatment plan that includes chronic opioid prescribing. Further, we wish to clarify best practices based on consensus and data where available.

METHODS

A 20-item membership survey was sent to Texas Pain Society members. A group of chronic pain experts from the Texas Pain Society undertook an effort to review the best practices in the literature. The rationale for current UDT practices is clarified, with risk management strategies outlined, and recommendations for UDT outlined in detail. A detailed insight into the limitations of point-of-care (enzyme-linked immunosorbent assay, test cups, test strips) versus the more sensitive and specific laboratory methods is provided.

LIMITATIONS

Our membership survey was of a limited sample size in one geographic area in the United States and may not represent national patterns. Finally, there is limited data as to the efficacy of UDT practices in improving compliance and curtailing overall medication misuse.

CONCLUSIONS

UDT must be done routinely as part of an overall best practice program in order to prescribe chronic opioid therapy. This program may include risk stratification; baseline and periodic UDT; behavioral monitoring; and prescription monitoring programs as the best available tools to monitor chronic opioid compliance.

I get tired for no reason: a single item screening for cancer-related fatigue

This study examined the criterion validity and sensitivity and specificity of a single item to rapidly screen patients in ambulatory oncology clinics for cancer-related fatigue. In an effort to expand the utility of the Zung Self-Rating Depression Scale (ZSDS) as a screen for other symptoms, the utility of the single fatigue item was examined. The fatigue item reads "I get tired for no reason" and is rated on a four-point scale ranging from "none or a little of the time" to "most or all of the time." Fifty-two subjects were administered the Zung, the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale, and the Fatigue Symptom Inventory (FSI). The Zung item was highly correlated with the ZSDS (r= 0.63, p < 0.0001) and the FACT-An (r = -0.70, p < 0.0001), as well as to the individual items of the FSI, ranging from 0.41 (p < 0.003) to 0.71 (p < 0.0001). All 10 subjects considered to be depressed based on the ZSDS were also considered to fatigued on the FACT-An. Setting the ZSDS item cutoff point at level 3--"A good part of the time"--yielded a sensitivity of 78.95% and a specificity of 87.88%. It is concluded that a single item can be a fast and accurate way of screening cancer patients for fatigue to trigger additional follow-up, thus expanding the utility of a depression screening tool for problems other than the purely psychiatric.

Symptom prevalence, characteristics, and distress in AIDS outpatients

Symptom distress is an important but poorly characterized aspect of quality of life in AIDS patients. To assess and characterize the symptoms and symptom distress associated with AIDS, 504 ambulatory patients with AIDS were evaluated between December, 1992 and December, 1995. The assessment included measures of symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. Patients described symptoms during the previous week using the Memorial Symptom Assessment Scale Short Form (MSAS-SF), a validated measure of physical and psychological symptom distress. The mean age was 38.6 years (range 18-69); 56% were male. African-Americans comprised 40% of the sample, Caucasians 35%, and Hispanics 23%. Ninety-three percent had CD4+ T-cell counts below 500, and 66% had counts below 200; 69% were classified in CDC category C (history of AIDS-defining conditions). Fifty-two percent reported intravenous drug use. Karnofsky performance status was > or = 70 in 80% of the patients. No patients were taking protease inhibitors. The mean (+/- SD) number of symptoms was 16.7 +/- 7.3. The most prevalent symptoms were worrying (86%), fatigue (85%), sadness (82%), and pain (76%). Patients with Karnofsky performance scores < 70 had more symptoms and higher symptom distress scores than patients with scores > or = 70 (21.2 +/- 6.5 vs. 15.6 +/- 7.1 symptoms/patient; 2.3 +/- 0.8 vs. 1.6 +/- 0.8 on the Global Distress Index [GDI] of the MSAS-SF; P < 0.0001 for both). Patients who reported intravenous drug use as an HIV transmission factor reported more symptoms and higher overall and physical symptom distress than those who reported homosexual or heterosexual contact as their transmission factor (17.8 +/- 7.5 vs. 15.4 +/- 6.9 symptoms/patient, P = 0.0002; 1.9 +/- 0.9 vs. 1.6 +/- 0.8 on the MSAS-GDI, P = 0.002). Both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life; for example, r = -0.69 (P < 0.0001) between GDI scores and scores on a validated measure of quality of life. Neither gender nor CD4+ T-cell count was associated with symptom number or distress. Responses from this self-referred sample of AIDS outpatients indicate that AIDS patients experience many distressing physical and psychological symptoms and a high level of distress. Both the number of symptoms and the distress associated with them are associated with a variety of disease-related factors and disturbances in other aspects of quality of life. Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life.

The role of religious and spiritual beliefs in coping with malignant melanoma

This study investigated the role of spiritual and religious beliefs in ambulatory patients coping with malignant melanoma. One-hundred and seventeen patients with melanoma being seen in an outpatient clinic completed a battery of measurements including the newly validated Systems of Belief Inventory (SBI-54). No correlation was found between SBI-54 scores and levels of distress. However, there was a correlation between greater reliance on spiritual and religious beliefs and use of an active-cognitive coping style (r = 0.46, p < 0.0001). Data suggest that use of religious and spiritual beliefs is associated with an active rather than passive form of coping. We suggest that such beliefs provide a helpful active-cognitive framework for many individuals from which to face the existential crises of life-threatening illness.

Psychological adjustment and suicidal ideation in patients with AIDS

This article assesses the psychosocial adjustment to illness and examines the relationship between adjustment and psychosocial and medical variables in 91 ambulatory HIV-infected patients. The 91 subjects were receiving ambulatory medical care in hospitals (Memorial Hospital, New York Hospital, and St. Vincent's Hospital) and in private medical consult (Gay Men's Health Crisis) in New York. The majority (74.5%) of subjects had AIDS. The sample was composed principally of white Roman Catholic homosexual men living alone. However, 49.5% were black or hispanic, 31.9% had intravenous drug use as their HIV risk behavior, 54.9% had past psychiatric history (including illegal drug use), and 22% had previous suicide attempts. Self-report measures of psychological adjustment (Psychological Adjustment to Illness Scale), mood (Brief Symptom Inventory), physical (PHYS) and psychological (PSYCH) symptoms from the Memorial Symptom Assessment Scale-Short Form (MSAS-SF), social support (Social Support Questionnaire-Short Report), suicidal ideation (Scale for Suicide Ideation Self-Report), and measures of disease status (Karnofsky Performance Rating Scale, HIV CDC Classification, and Absolute CD4+ Lymphocyte Count) were used in the study. The average age of subjects was 40 years (SD = 6.80). fifty-two (63.4%) subjects acknowledged some indication of suicidal ideation. Variables that correlated with poor medical adjustment (health-care posture) were current suicide ideation (0.32, p = 0.003), number of psychological symptoms (0.45, p = 0.0001), physical symptoms (0.31, p = 0.006), social support (-0.24, p = 0.03), and satisfaction with the social support received (-0.36, p = 0.001). Poor sexual adjustment was related to current suicide ideation (0.39, p = 0.0004), number of psychological symptoms (0.40, p = 0.0003), satisfaction with the social support received (-0.28, p = 0.01), and number of physical symptoms (0.35, p = 0.002). In patients with a diagnosis of AIDS, the number of psychological symptoms (Beta = 0.29, R2 = 0.07, p = 0.02) and the satisfaction with the social support received (Beta = -0.38, R2 = 0.14, p = 0.003) were clear predictors of poor medical adjustment (health-care posture). Likewise, the predictors of poor sexual adjustment were psychological symptoms (Beta = 0.33, R2 = 0.10, p = 0.003) and suicidal ideation (Beta = 0.40, R2 = 0.10, p = 0.002). The results suggest that suicide ideation is associated with poor adjustment, rather than serving as an adaptive function, as has been suggested by others.

A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness

This paper reports on the initial efforts to validate a brief self-report inventory, the Systems of Belief Inventory(SBI-15R), for use in quality of life (QOL) and psychosocial research studying adjustment to illness. The SBI-15R was designed to measure religious and spiritual beliefs and practices, and the social support derived from a community sharing those beliefs. The authors proposed this scale to address the need for greater exploration of spiritual and religious beliefs in QOL, stress and coping research. Phase I: Item generation. The research team identified four domains comprised of 35 items that make up spiritual and religious beliefs and practices. The instrument was piloted in a structured interview format on 12 hospitalized patients with varying sites of cancer. Phase II: Formation of SBI-54. After these initial efforts, the research team increased the number of items to 54 and adopted a self-report format. To assess patients reactions to the questionnaire, the new version was piloted on 50 outpatients with malignant melanoma. Phase III: Initial validation. To begin establishing validation, 301 healthy individuals with no history of cancer or serious illness in the prior year were asked to complete the SBI-54 and several other instruments. A principal components analysis with varimax rotation of the SBI-54 identified two factors, in contrast to the four which were hypothesized, one measuring spiritual beliefs and practices, the other measuring social support related to the respondent's religious community. Phase IV: Item reduction of the SBI-54. A shortened version of the SBI-54 with 15 items, five from the items identifying factor I and ten from those identifying factor II, was developed to lessen patient burden. The new SBI-15 correlated highly with the SBI-54, and demonstrated convergent, divergent, and discriminant validity. Revision of SBI-15. The investigators rephrased one statement in order to broaden the applicability of the SBI-15 to patients other than those with a diagnosis of cancer, and to healthy individuals. DISCUSSION. The SBI-15R met tests of internal consistency, test-retest reliability, and convergent, divergent, and discriminant validity in both physically healthy and physically ill individuals. The SBI-15R may have value in measuring religious and spiritual beliefs as a potentially mediating variable in coping with life-threatening illness, and in the measurement of QOL.

Progress toward guidelines for the management of fatigue

Fatigue is a subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Cancer-related fatigue has many causes. Included in the causes are the illness itself, the side effects of virtually every treatment, depression, and other biopsychosocial factors. As a result, fatigue is the most common symptom reported by cancer patients in most descriptive studies. In addition to arising from multiple etiologies, fatigue is also multidimensional in its manifestation and impact. Its effect on the quality of life of the patient is comparable to that of pain. Experienced by most patients as an extremely frustrating state of chronic energy depletion, it leads to loss of productivity which can reduce self-esteem. As a subtle and chronic symptom, it also places people at risk for being questioned about the veracity of their complaints, particularly during the post-treatment, disease-free survival period. Patients themselves are reluctant to complain of fatigue, perhaps because they believe little can be done about it, or they wish to avoid drawing attention away from treating their cancer.

Surgeon-patient communication in the treatment of pancreatic cancer

BACKGROUND

Effective physician-patient communication has been correlated with patient satisfaction and improved outcome. Pancreatic cancer (PC) is a disease with an overwhelmingly poor prognosis that requires a complex level of communication and emotional support. Since the treatment of PC is often surgical, surgeons play a central role in the care of these patients.

OBJECTIVES

To assess the quality of long- and short-term surgeon-patient communication. To assess the role of the surgeon in the emotional support of patients with PC.

DESIGN

Combined mail and telephone survey of a case series of patients who had undergone a pancreatic resection for PC.

SETTING

Urban tertiary cancer referral center.

PATIENTS

Forty-eight patients who underwent pancreatic resection for PC.

INTERVENTION

Pancreatic resection.

MAIN OUTCOME MEASURE

Patient satisfaction.

RESULTS

Forty-eight patients completed surveys for a response rate of 70%. Patients were extremely satisfied with the information provided by their surgeon before surgery and while in the hospital. However, 21% of patients reported an unexpected outcome of their operation and 27% had questions about their disease at the time of the survey. Patients were largely satisfied with the emotional support they had received while in the hospital and after discharge. The attending surgeon was the most commonly desired source of additional emotional support.

CONCLUSIONS

While surgeon-patient communication was extremely effective before surgery and during hospitalization, patients developed long-term questions and dissatisfaction after discharge from the hospital. Strategies to improve long-term support and communication would benefit a significant number of patients with operable PC. Surgeons play an important role in the emotional support of patients with operable PC.

Patient-related barriers to pain management in ambulatory AIDS patients

A number of studies have demonstrated that pain is dramatically undertreated among patients with AIDS and that opioids in particular are rarely prescribed. To date, however, there has been no systematic attempt to examine patient-related barriers to the management of pain in AIDS. This study examines potential patient-related barriers to pain management in patients with AIDS using the Barriers Questionnaire (Ward et al., Pain, 52 (1993) 319-324), and assesses gender, racial, and other demographic differences in the endorsement of these barriers. We surveyed 199 ambulatory patients with AIDS, recruited from numerous sites in New York City, as part of an ongoing study of pain and quality of life in ambulatory AIDS patients. In addition to obtaining demographic and medical data, we administered a number of self-report questionnaires including the Brief Pain Inventory (BPI), the Brief Symptom Index (BSI), the Beck Depression Inventory (BDI), and the Memorial Symptom Assessment Scale (MSAS). Barriers to pain management were assessed using a modified version of the Barriers Questionnaire (BQ), including the original 27 questions from this self-report instrument along with an additional 12 items developed for an AIDS population. Results indicated that the most frequently endorsed BQ items were those concerning the addiction potential of pain medications and physical discomfort associated with opioid administration (e.g. injections) or side effects (e.g. nausea, constipation). There were no associations between age, gender, or HIV transmission risk factor and total scores on the BQ; however, Caucasian patients endorsed significantly fewer BQ items than did non-Caucasian patients and years of education was negatively correlated with BQ scores. Scores on the BQ were also significantly correlated with number of physical symptoms (MSAS) and scores on several self-report measures of psychological distress (the BSI Global Distress Index, BDI total scores). Patient-related barriers (i.e. BQ total scores) were significantly associated with undertreatment of pain (as measured by the Pain Management Index), and added significantly to the prediction of undertreatment in a logistic regression analysis, even after controlling for the impact of gender, education and IDU transmission risk factor. These data suggest that patient-related barriers to pain management may add to the already considerable likelihood of undertreatment of AIDS-related pain.

Fatigue in ambulatory AIDS patients

Although preliminary reports indicate that fatigue is a common symptom of human immunodeficiency virus (HIV) disease, little empirical research has focused on its prevalence or characteristics among patients with acquired immunodeficiency syndrome (AIDS). We assessed the frequency of fatigue and its medical and psychological correlates, in a cross-sectional survey of ambulatory AIDS patients. Ambulatory patients with AIDS who participated in a study of quality life (N = 427) were classified into fatigue/no fatigue groups based on their responses to fatigue items on the Memorial Symptom Assessment Scale (MSAS) and the AIDS physical symptom checklist. Self-report inventories were also administered to assess psychological distress, depressive symptoms, and overall quality of life. Medical information was elicited through clinical interview and review of medical chart. Fifty-four percent of the patients endorsed both of the fatigue items from the MSAS and the AIDS physical symptom checklists, and were classified as having fatigue. Women were significantly more likely to report fatigue than men (chi square = 5.28, df = 1, P < 0.03), and patients reporting homosexual contact as their transmission risk factor were significantly less likely to report fatigue than were patients reporting injection drug use or heterosexual contact (chi square = 5.13, df = 2, P < 0.03). The presence of fatigue was significantly associated with the number of current AIDS-related physical symptoms [t(425) = 8.00, P < 0.0001], current treatment for HIV-related medical disorders (chi square = 12.51, df = 1, P < 0.0001), anemia [t(174) = -2.35, P < 0.02], and pain (chi square = 36.36, df = 1 P < 0.0001). Patients with fatigue also had significantly poorer physical functioning ability [Karnofsky: t(422) = -6.27, P < 0.0001], as well as greater degree of overall psychological distress and lower quality of life [F(5,418) = 23.79, P < 0.0001], as measured by the Brief Symptom Inventory, Beck Depression Inventory, Beck Hopelessness Scale, Functional Living Inventory for Cancer (modified for AIDS), and the MSAS Psychological Distress Subscale. Fatigue is a common symptom in ambulatory AIDS patients and is associated with significant physical and psychological morbidity.

A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse

Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use. This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors. Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire. Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference. However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress. There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program. These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs.

Pain syndromes and etiologies in ambulatory AIDS patients

Ambulatory AIDS patients participating in a quality of life study were recruited for an assessment of pain syndromes. Of 274 patients with pain, 151 (55%) consented to the assessment which included a clinical interview, neurologic examination, and review of medical records. The number, type, and etiology of pains were evaluated in terms of risk factors, age, sex, CD4+ lymphocyte count, and performance status. The average number of pains per patient was 2.7 (range, 1-7), yielding a total of 405 pains. The most common pain diagnoses were headache (46% of patients; 17% of all pains), joint pain (31% of patients; 12% of pains), pain due to polyneuropathy (28% of patients; 10% of pains), and muscle pain (27% of patients; 12% of pains). Pathophysiology was inferred for all pain syndromes (except for headache), 45% of pain syndromes were somatic in nature, 15% were visceral, 19% were neuropathic, and 4% were unknown, psychogenic, or idiopathic; 17% of pains were classified as headache, hence pathophysiology could not be determined. Pain resulted from diverse etiologies, including the direct effects of HIV/AIDS-related conditions (30%) pre-existing unrelated conditions (24%), and therapies for HIV/AIDS and related conditions (4%). The latter category, pain related to HIV therapies, occurred in 11% of patients. In 37% of the pains, the etiology could not be determined from the information available. In univariate analyses, lower CD4+ cell counts were significantly associated with polyneuropathy (P < 0.05) and headache (P < 0.05), and female gender was significantly associated with the presence of headache (P < 0.05) and radiculopathy (P < 0.001). These data confirm the diversity of pain syndromes in AIDS patients, clarify the prevalence of common pain types, and suggest associations between specific patient characteristics and pain syndromes. The large proportion of patients who could not be given a diagnosis underscores the need for a careful diagnostic evaluation of pain in this population.

The Memorial Delirium Assessment Scale

We conducted two studies with medically hospitalized cancer and acquired immunodeficiency syndrome (AIDS) patients to assess the reliability and validity of a new measure of delirium severity, the Memorial Delirium Assessment Scale (MDAS). The first study used multiple raters who jointly administered the MDAS to 33 patients, 17 of whom met DSM III-R/DSM IV criteria for delirium, 8 met diagnostic criteria for another cognitive impairment disorder (for example, dementia), and 8 had non-cognitive psychiatric disorders (for example, adjustment disorder). Results indicate high levels of inter-rater reliability for the MDAS (0.92) and the individual MDAS items (ranging from 0.64 to 0.99), as well as high levels of internal consistency (coefficient alpha = 0.91). Mean MDAS ratings differed significantly between delirious patients and the comparison sample of patients with other cognitive impairment disorders or no cognitive impairment (P < 0.0002). The second study compared MDAS ratings of 51 medically hospitalized delirious patients with cancer and AIDS made by one clinician to ratings on several other measures of delirium (Delirium Rating Scale, clinician's ratings of delirium severely) and cognitive functioning (Mini-Mental State Examination) made by a second clinician. Results demonstrated a high correlation between MDAS scores and ratings on the Delirium Rating Scale (r = 0.88, p < 0.0001), the Mini-Mental State Examination (r = -0.91, P < 0.0001), and clinician's global ratings of delirium severity (r = 0.89, P < 0.0001). Thus, our findings indicate that the MDAS is a brief, reliable tool for assessing delirium severity among medically ill populations that can be reliably scored by multiple raters. The MDAS is highly correlated with existing measures of delirium and cognitive impairment, yet offers several advantages over these instruments for repeated assessments which are often necessary in clinical research.

Lymphedema complicated by pain and psychological distress: a case with complex treatment needs

One complication of breast cancer treatment is lymphedema of the ipsilateral arm. The one-third of lymphedema patients who experience pain report more functional interference, psychiatric symptoms, and distress related to intrusive and avoidant thoughts than patients without pain. Lymphedema patients with pain also report higher levels of body image disturbance and decreased sexual drive. We present a case example illustrating how pain can undermine rehabilitative efforts and detract from quality of life. In addition, the most common causes of pain in patients with upper extremity lymphedema are discussed. Pain related to lymphedema is a neglected aspect of this often overlooked problem in breast cancer survivorship.

Development and validation of a patient needs assessment tool (PNAT) for oncology clinicians

The Patient Needs Assessment Tool (PNAT) is an interviewer-rated scale that may be completed through a simple structured interview and screens cancer patients for potential problems in physical and psychosocial functioning. The instrument provides separate scores for physical, psychological, and social status, and can potentially clarify the types of interventions needed to address specific areas of dysfunction. Reliability and validity was tested in two studies that used prescreened patient videotapes and other materials to assess the performance of the PNAT in groups of oncology nurses, physicians, and social workers. The data demonstrate that subscale scores for the physical, psychological, and social dimensions have good inter-rater reliability and internal consistency (intraclass correlation coefficients of 0.71-0.97). Criterion and construct validity was suggested through high correlations of each subscale with the evaluation of expert raters (correlation coefficients of 0.85-0.95) and with scores on validated patient-rated instruments appropriate to the functional area. These analyses suggest that the PNAT is a valid scale for the assessment of a range of functional disturbances in the cancer population.

Psychiatric consultation for women undergoing rehabilitation for upper-extremity lymphedema following breast cancer treatment

Breast cancer presently affects one in nine women in the United States. Women receiving radiation and surgical resection of axial lymph nodes are at risk for development of lymphedema of the ipsilateral upper extremity. Mental health consultation and intervention can be an important part of rehabilitative efforts aimed at improving both lymphedema itself and the overall psychosocial adjustment of the patient. Such consultation begins with a careful consideration of possible psychiatric diagnosis but must necessarily depart from standard psychiatric considerations to include an assessment of psychosexual and social factors. Additionally, the consultant must gauge the degree of success the patient has had in adjustment to lifestyle changes brought on by lymphedema. This paper discusses the psychological problems posed by lymphedema and offers case examples. These cases illustrate the nature of psychiatric and psychological factors encountered in this population and the interventions that can help improve both compliance with rehabilitative efforts and psychological adjustment.

The need for multidisciplinary training in counseling the medically ill. Report of the training committee of the Linda Pollin Foundation

Training for medical counselors requires that medicine and psychiatry give up the position that counseling is only a negligible offshoot that almost any professional can readily do. Instead, counseling can be considered a generic concept that covers a wide variety of interventions designed to help patients cope with the complications and consequences of their chronic illness. This report outlines the principles and scope of training for consideration in the area of counseling the medically ill and reviews the current status of training programs in the fields of psychiatry, psychology, social work, and nursing. Recommendations are made for future directions, including role clarification for disciplines, building a credible research base, provision of guidelines and possible accreditation, and incorporating medical counseling into training fellowships.