{"id":313,"date":"2020-05-29T16:57:45","date_gmt":"2020-05-29T20:57:45","guid":{"rendered":"http:\/\/harmsprogram.ca\/?page_id=313"},"modified":"2020-06-08T13:38:18","modified_gmt":"2020-06-08T17:38:18","slug":"managing-udt-results","status":"publish","type":"page","link":"https:\/\/harmsprogram.ca\/harms-program\/9-managing-udt-results","title":{"rendered":"Chapter 9: Managing UDT Results"},"content":{"rendered":"
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Now that we have an understanding of how to interpret UDT results, it is important to understand how to act on the full spectrum of concerns…<\/em><\/p>\n<\/div>\n\t\t<\/div><\/div><\/div><\/div>

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UDT results will fall along a spectrum ranging from expected, to mild aberrancy, to major aberrancy. There is also an axis for level of certainty in the result – from low level of certainty (high potential for false positive or false negative) to high level of certainty. This wide range of results must then be applied to a wide range of patients who will have innumerable other unique factors that contribute to the overall clinical Gestalt. You can see that there are an infinite number of scenarios so memorizing approaches without a deeper understanding of what we are doing is not possible. Understanding the big picture when applying UDT results is critical. UDT is meant to contribute to the clinical Gestalt, as we weigh the risks and benefits of prescribing opioids. It is not meant to be a replacement for clinical Gestalt.<\/p>\n

By understanding the important factors that suggest someone is being helped or harmed by opioids, we can make more informed decisions about if\/how we prescribe them.<\/p>\n

The decision about if and how to prescribe opioids essentially comes down to weighing risks against benefits. The Clinical Gestalt will fall along a spectrum ranging from Benefits>>Risks, to Risks>>Benefits. When we first start someone in HARMS, we are estimating which scale is most representative of this patient. When new information such as UDT results come in, the scales may tip and the risk category changes. This chapter will primarily cover what factors we should consider when assessing where a patient falls and how we should adjust the balance based on new information (such as UDT results).<\/p>\n<\/div>\n\t\t<\/div><\/div><\/div><\/div>

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Benefits>>Risks
Low Risk - infrequent UDT, longer dispensing intervals.<\/p>\n\t\t<\/div>\n\n\t\t

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Benefits~Risks
High risk - consider alternative treatment options - if continuing to prescribe opioids then very short intervals, frequent UDT.<\/p>\n\t\t<\/div>\n\n\t\t

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Risks>>Benefits
Taper and stop (or if OUD is identified, rotate on to OAT).<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t

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Benefits>Risks
Medium Risk - infrequent UDT, shorter dispensing intervals.<\/p>\n\t\t<\/div>\n\n\t\t

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Risks>Benefits
Patient should probably have opioids tapered and stopped (unless opioid addiction is identified in which case you would rotate to OAT).<\/p>\n\t\t<\/div>\n\t\t\n\t\t

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However, if you decide to keep prescribing opioids for \u201cpain\u201d in this patient then you may consider a hybrid between opioids for pain and opioids for addiction in which you have daily dispensing and frequent UDT (we call this the \u201cstructured\u201d stream).

\nThe only challenge is that if truly treating pain then you generally would be using TID-QID dosing, whereas OAT is typically OD dosing. While both would have daily observed dosing at the pharmacy, the \u201cpain\u201d patient would typically get take-home doses (or multiple observed doses at the pharmacy). You will have to use clinical judgement about take-home doses or consider using 24hr-release morphine formulations if comfortable.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div>

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To illustrate how the scale will tip based on new information, imagine a patient that is high risk has new and concerning UDT results. You can see how the risks side becomes heavier, and now our overall risk\/benefit assessment has shifted. We must therefore adapt our prescribing\/monitoring approach to this new information, and evolving risk category.<\/p>\n

So if the decision of if\/how to prescribe opioids – and how to adapt to new information – comes down to weighing the risks\/benefits, what types of factors contribute towards this risk\/benefit balance?<\/p>\n<\/div>\n\t\t<\/div><\/div>

Markers of Benefit from opioids may include:<\/strong>
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