PtProtect® – Case Studies

Case #1: Multiple Physicians

Facts:

A patient receiving Vicodin® (hydrocodone) for chronic pain from his primary care clinician requests an increase in dose. Before increasing the dose of hydrocodone the clinician orders 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 indicates that he is also seeing another clinician for pain who prescribed oxymorphone.
  • The patient acknowledges he regularly drinks wine with dinner. The clinician informs the patient of the dangers (respiratory depression) of taking two opioid analgesics together and drinking alcohol.
  • The primary care clinician requests the patient to immediately discontinue oxymorphone use and reduce alcohol intake. The clinician makes a note in the patient's record to retest in one month to monitor compliance.

Case #2: Diversion to the Street

Facts:

A primary care clinician had previously prescribed 10 mg Oxycontin® (oxycodone), q12h, for a 29 year old woman who complained of chronic back-pain following a minor auto accident and two months of physical therapy. Since the patient was not well known to the clinician, she ordered a PtProtect pain medication management panel to check adherence 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 indicates a positive 6-MAM is 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 says the morphine positive test result was from the poppy-seed muffins she eats every morning. The PtProtect interpretation does not support the potential for poppy-seed ingestion because the free morphine level exceeded 300 ng/mL. Upon further discussion, the patient admits 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 year old woman is on long-term MS Contin® (morphine), 60 mg q12h, for pain due to fibromyalgia. Clinician A orders a urine morphine level to provide annual adherence documentation.

Meanwhile Clinician B, in a town 65 miles away from Clinician A, prescribes the same patient oxycodone and orders a urine oxycodone level to provide annual adherence documentation.

Results:

As expected by Clinician A, the morphine level was positive at 3,678 ng/mL, consistent with the MS Contin® prescription.

As expected by Clinician B, the oxycodone level was positive at 1,645 ng/mL, consistent with the oxycodone prescription.

Because Clinician A and Clinician B only tested for single drugs, they did not know the patient was taking two narcotic analgesics. The laboratory was aware the patient had two opioids present but was unable to alert the clinicians due to HIPAA regulations.

Outcome:

One month later, this patient is found deceased at home. The autopsy toxicology report indicates the presence of oxycodone, morphine and temazepam. The medical examiner signs 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 yet another clinician, 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 medication management panel is recommended when testing patients for opioid/opiate adherence. PtProtect detects multiple opioid/opiates, 6-MAM for heroin detection, benzodiazepines, and illicit drugs. If either Clinician A or B had ordered PtProtect in place of a single opioid test, they would have found the second prescribed opioid and temazepam (Restoril).​​​