PtProtect® – Case Studies
Case #1: Multiple Physicians
Facts:
A patient receiving Vicodin® (hydrocodone) for chronic pain from his primary care physician requests an increase in dose. Before increasing the dose of hydrocodone the physician ordered a PtProtect™ Pain Management Panel.
Results:
Urine Drug Levels
Hydrocodone = 1250 ng/mL
Hydromorphone = 25 ng/mL
Oxymorphone = 110 ng/mL
Ethanol = 0.030 g/dL
Interpretation:
The PtProtect interpretation indicates hydromorphone is a metabolite of hydrocodone and is consistent with prescribed use of hydrocodone. The oxymorphone positive result was unexpected.
Patient Follow-up:
- After probing, the patient indicated that he was also seeing another physician for pain who prescribed oxymorphone.
- The patient acknowledged he regularly drinks wine with dinner. The physician informed the patient about the dangers (respiratory depression) of taking two opioid analgesics together and drinking alcohol while taking opioids.
- The primary care physician requested that the patient immediately discontinue oxymorphone use and reduce alcohol intake. The physician made a notation to retest the patient in one month to monitor compliance.
Case #2: Diversion to the Street
Facts:
A primary care physician had previously prescribed 10 mg Oxycontin® (oxycodone), q12h, for a 29 y.o. woman with complaint of chronic back-pain following a minor auto accident and 2 months of physical therapy. Since the patient was not well known to the physician, she ordered a PtProtect Pain Management Panel to check compliance before renewing the oxycodone prescription.
Results:
Urine Drug Levels
Oxycodone = negative
Oxymorphone = negative
Morphine = 7082 ng/mL
6-monoacetylmorphine = 126 ng/mL
Marijuana metabolite = 45 ng/mL
Interpretation:
The PtProtect report was negative for oxycodone and its metabolite oxymorphone but positive for morphine, 6-monoacetylmorphine (6-MAM) and marijuana. The report’s interpretation indicated that the positive 6-MAM was definitive proof for recent heroin use. The morphine test result was consistent with heroin use since heroin is metabolized to 6-MAM and morphine.
Patient Follow-up:
The patient said the morphine positive was from the poppy-seed muffins she eats every morning. The PtProtect interpretation did not support the potential for poppy-seed ingestion because the free morphine level exceeded 300 ng/mL. Upon further discussion, the patient admitted to selling oxycodone tablets to fund her heroin habit.
Case #3: Medication Safety—
Why a Single Opioid Drug Test Order is Insufficient
Facts:
A 38 y.o. female on long-term MS Contin® (morphine), 60 mg q12h, for pain due to fibromyalgia. Physician A ordered a urine morphine level to provide annual compliance documentation.
Meanwhile Physician B, in a town 65 miles away from Physician A, prescribed the same patient oxycodone and ordered a urine oxycodone level to provide annual compliance documentation.
Results:
As expected by Physician A, the morphine level was positive at 3678 ng/mL, consistent with the MS Contin® prescription.
As expected by Physician B, the oxycodone level was positive at 1645 ng/mL, consistent with the oxycodone prescription.
Because Physician A and Physician B only tested for single drugs, they did not know that the patient was taking two narcotic analgesics. The laboratory was aware the patient had two opioids present but was unable to alert the physicians due to HIPAA regulations.
Outcome:
One month later, this patient was found deceased at home. The autopsy toxicology report indicated the presence of oxycodone, morphine and temazepam. The medical examiner signed out the case as an accidental death from respiratory failure due to the combination of two opioids and a benzodiazepine (Restoril). The sedative hypnotic Restoril was prescribed by Physician C, an urgent care physician, who treated the patient for insomnia associated with anxiety.
Results if Pain Management Panel Ordered:
Urine Drug Levels
Morphine = 3678 ng/mL
Oxycodone = 1645 ng/mL
Oxymorphone = 38 ng/mL
Benzodiazepine (temazepam) = positive
A PtProtect Pain Management Panel should be ordered when testing patients for opioid/opiate compliance. PtProtect detects multiple opioid/opiates, 6-MAM for heroin detection and the common drugs of abuse. If either Physician A or Physician B had ordered PtProtect in place of a single opioid test, they would have found the second prescribed opioid and temazepam (Restoril).
