Staying Safe: The Importance of Medication Monitoring as the Pandemic Continues

Clinical Update
September 2021

Staying Safe: The Importance of Medication Monitoring as the Pandemic Continues

The COVID-19 pandemic continues to pose significant challenges to the healthcare system, despite widespread availability of vaccines. Variants of the virus are spreading and causing heavy burdens on hospital systems across the country. Many healthcare systems have revisited policies and procedures that were first implemented when the pandemic first began and are serving patients via telehealth. Much has been learned about the impact of lockdowns, loss of employment, general fear and anxiety, illness, isolation, and other effects of the COVID-19 pandemic. This knowledge can be applied to re-approach medication monitoring in a more informed manner and potentially reduce the continued ripple effects of the pandemic on society. 

Pain Management and Behavioral Health Care During the COVID-19 Pandemic

The COVID-19 pandemic has been a catalyst for patients falling into a cycle by which they can be lost from the healthcare system into a vacuum of substance misuse. Events caused by the pandemic can trigger loss of employment, loss of healthcare coverage, or periods of isolation due to illness or caring for a family member or contact tracing. 

 

Patients may miss appointments or lose access to healthcare services due to these events, or otherwise become disengaged with their care plan or goals. Pain control, continued abstinence, or stability of mental health can be lost as patients turn to self-treatment strategies. This can occur in the form of overuse of prescribed medications or misuse of non-prescribed or illicit substances. As a result, patients may engage in aberrant behavior to attempt to maintain access to prescription drugs. This aberrant behavior may cause further loss of care or warrant more specialized care which the patient may not have access to during the pandemic. [WJ1] Additional accelerants to this process may include psychosocial issues and previously co-occurring substance use and behavioral health disorders.

Breaking the Cycle

Clinicians may need to consider creative and comprehensive solutions to intercept this cycle and help keep patients on track. Each element of the cycle can be addressed with evidenced-based tools to avoid the potentially life-threatening effects of substance use disorder (SUD).

Reduced Access to Care

Providing clinical care has looked very different at times through the course of the COVID-19 pandemic. Telemedicine allows for patients to maintain their visit schedule without in-person contact. However, medication monitoring tools such as drug testing may need to be adjusted to continue to accommodate the telehealth model. In order to maintain the ability to monitor medication and substance use, providers may utilize drive-up specimen collections, mobile specimen collection, and remote oral fluid collections via the AegisFLEX program.

Disengagement with Treatment Goals

Reduced access to care can complicate the continued prescribing of a patient’s therapeutic regimen. Some patients may require the continued prescribing of controlled substances during the pandemic, even when in-person office visits have been put on hold.  The Drug Enforcement Administration has provided a web page of COVID-19 resources to help providers navigate the changing regulations regarding controlled substance prescribing.1 With telehealth and flexible prescribing models, this can allow for patient treatment to continue as planned.

Self-Medication

Patients may turn to self-medication with old prescriptions they have on hand or the prescriptions of family and friends or may seek out non-prescribed substances such as marijuana, alcohol, or illicit drugs to attempt to relieve pain, anxiety, or depression. Even with continued care, patients may still use non-prescribed or illicit substances to cope with changing circumstances in their lives and in the world around them. Typically, this is not something that patients will self-report. Objective measures such as drug testing help identify inappropriate substance use and can reduce the risk of negative outcomes.

With changes in medications, lack of continuity of care, and possible non-prescribed drug use that may be ongoing during the pandemic, multiple factors could be contributing to increased risk for drug interactions. Drug interaction testing may provide valuable clinical details in patients who show intolerance to prescribed therapy, a reduced response to therapy, or require dose escalations for effective treatment. Patients may also be at increased risk for drug interactions if their medication profile may be incomplete due to the complexity of their past medical history. Also, some patients may be at increased risk of morbidity from drug-drug interactions.

Testing for a broad array of substances may be necessary depending on the clinician’s assessment of the patient’s level of risk. At the provider’s discretion, testing may be ordered for novel psychoactive substances (NPS), which can cause life-threatening effects if used alone or in combination with other drugs. Drug interactions between NPS and prescription drugs are also possible. NPS and/or Illicit fentanyl may also be incorporated into counterfeit pills. As of January 2020, 49 U.S. states have reported fentanyl-laced counterfeit pills, with deaths attributed to such pills in 38 states.2

Aberrant Behavior

Patients who have gone off-course with treatment goals may engage in aberrant behaviors to attempt to mask substance misuse or drug diversion. Testing strategies that can assist with identifying specimen tampering, adulteration, and substitution may be helpful in identifying aberrant behavior.  Aegis offers an expanded specimen validity testing tool called BioDetectTM, which is performed on all urine specimens to identify patient specimens that have been substituted using synthetic urine. Through the identification of unique markers expected in human urine, healthcare providers will have greater insight into patients' medication adherence. BioDetect results are reported as Expected or Not Expected. If the result is Not Expected, clinicians are encouraged to contact the Aegis Clinical Team for assistance with interpretation. If future collections for the patient are planned, they should be observed, or oral fluid testing should be considered which allows for direct observation of the patient during collection.

Specimen tampering may also be evidenced by urine specimen results that are flagged for absence of metabolites. Urine drug concentrations of metabolites typically exceed parent drug concentrations, so when expected metabolites of a drug are not detected in urine testing, this can indicate specimen tampering in some cases. There may be a clinical explanation for parent-only results in some cases, so it is recommended to discuss results with low or absent metabolites with the testing laboratory to ensure proper interpretation. As with sample substitution concerns, follow-up testing for patients who have exhibited parent-only urine drug test results may be observed or shifted to oral fluid testing to reduce the opportunity for aberrant behavior, if this is a concern.

Patients may try to avoid in-person visits, so having a telehealth arm to the drug testing protocol can cover such instances so the patient can still be tested. If patients do come into the clinic, they may state that they are unable to provide a urine sample, so having an alternative testing option such as oral fluid testing can help streamline patient visits and avoid lengthy wait times for patients to be able to provide urine samples. 

Further Loss of Care/Need for Specialized Care

At some point in the care relationship, a provider may determine it is in the best interest of the patient to refer them for behavioral health care needs or for more intensive SUD treatment.3-4 Children, adolescents, women who are or desiring to become pregnant, or individuals who have psychiatric diagnoses, such as opioid use disorder or SUD may require more specialized, intensive, or immediate care. Part of a holistic medication monitoring protocol includes plans to refer patients as appropriate, with documentation of such referrals to be included in the patient chart.

Provider Resources

Providers are encouraged to contact Aegis for more information on any of these topics. If a practice’s current medication monitoring protocol is not able to pivot with the pandemic or there may be gaps in monitoring based on the level of risk among the patient population, there are resources available to bridge these gaps according to the provider’s request and determination of medical necessity.

NOTICE: The information above is intended as a resource for health care providers. Providers should use their independent medical judgment based on the clinical needs of the patient when making determinations of who to test, what medications to test, testing frequency, and the type of testing to conduct.

References:

1. COVID-19 information page. https://www.deadiversion.usdoj.gov/coronavirus.html. Accessed August 23, 2021.
2. 2020 National Drug Threat Assessment. Drug Enforcement Administration. https://www.dea.gov/documents/2021/03/02/2020-national-drug-threat-assessment. Published March 2021. Accessed June 17, 2021.
3. Start your recovery. https://startyourrecovery.org/. Accessed August 23, 2021.
4. Findtreatment.gov. http://www.findtreatment.gov/. Accessed August 23, 2021.

NOTICE: The information above is intended as a resource for health care providers. Providers should use their independent medical judgment based on the clinical needs of the patient when making determinations of who to test, what medications to test, testing frequency, and the type of testing to conduct.

DOWNLOAD CLINICAL UPDATE