How the Opioid Crackdown Is Affecting Lab Enforcement & Test Utilization

• 103 in 1: Odds of dying in a motor vehicle crash
• 96 in 1: Odds of dying from an opioid overdose

The alarming finding that a person is now more statistically likely to die of an opioid overdose than a motor vehicle crash comes from The National Safety Council (NSC). And it’s only the latest reminder of how the opioid epidemic has transcended from a medical to a societal crisis. Of course, all of this is having more than a peripheral impact on medical labs.

The 2 Faces of the Epidemic
In 2017, the Trump administration declared the opioid crisis a public health emergency. In October 2018, new bipartisan legislation to deal with the problem was signed, including:

• The STOP Act (aka, Synthetics Trafficking and Overdose Prevention Act of 2018) providing for tougher postal screening and tighter manifest controls at ports of entry to prevent opioids and illegal drug distribution; and
• The SUPPORT Act (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act) which includes new measures to crackdown on opioid-related Medicare and Medicaid fraud and abuse.

Even as lawmakers and enforcement attempt to stem the flow of illegal opioids, the number of opioid users continues to grow because so many people get the drugs legally—at least initially. Accordingly, the crackdown on illegal drugs isn’t enough to solve the opioid crisis; misuse of prescription opioid misuse must also be addressed.

Misuse of Legal Prescription Opioids by the Numbers

• 130: The number of people who die of opioid overdoses in the U.S. each day;

• $78.5 Billion: The Centers for Disease Control and Prevention (CDC) estimates of the total “economic burden” of prescription opioid misuse in the U.S. per year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.

• 21 to 29: The approximate percentage of patients prescribed opioids for chronic pain and who misuse them;

• 8 to 12: The approximate percentage of patients prescribed opioids for chronic pain and who develop an opioid use disorder;

• 4 to 6: The approximate percentage of patients who misuse opioids who transition to heroin;

• 80: The approximate percentage of people who use heroin that got there by misusing prescription opioids.

Source: National Institutes of Health (NIH) data

Impact on Labs—Enforcement
In terms of Medicare fraud and abuse enforcement, the opioid epidemic has had a mixed impact on labs. The prioritization of opioid-related activities has diverted resources previously utilized to combat financial fraud; however, it has had the exact opposite effect on labs that provide urine drug testing services for physicians who prescribe opioid medications, particularly those who own the labs to which tests are referred. (See, LCA, Feb. 19, 2018, for more details on how opioid enforcement is affecting labs.)

Impact on Labs—Test Utilization
Lab testing capable of detecting the use/misuse of opioids is utilized by employers for employment and pre-employment screening, as well as by insurers and physicians to monitor the effects of legally prescribed opioids. However, according to Lab Tests Online, a program of the American Association for Clinical Chemistry (AACC), these tests don’t distinguish between opiates that come from natural sources (e.g., heroin and morphine) and semi-synthetic and synthetic opioids (e.g., oxycodone, hydrocodone, and fentanyl).

While this may actually turn out to be advantageous given the overlap in usage, a new approach is needed. With this in mind, AACC recommends that drug testing become more widespread. In addition to typical testing (work-related, court ordered, and treatment-related), it recommends that people get tested:

• When prescribed opioids for long-term (chronic) pain; and
• When a person has signs and symptoms suggesting drug intoxication or overdose.

Promoting this message while the NIH educates the public about opioid use could lead to an increase in voluntary lab tests. At the same time, as more people seek treatment, tests in connection with treatment programs will likely increase.

Testing Factors and Methods
Still, testing for opioids is not without challenges. Numerous factors affect how quickly an opiate leaves the system. According to American Addiction Centers, these include:

• The individual’s metabolism rate;
• Body mass and weight;
• Body fat content;
• Health of the liver and kidneys;
• Age;
• How often and how heavy opiate use is;
• Quality of the drug; and
• Amount of water in the body

What’s more, not all opiates stay in the system for the same length of time. Add to this the fact that different tests are more effective than others for different opiates. For example, according to American Addiction Centers, “a saliva test will only be able to detect heroin for the first five hours after the last dose, while blood tests can detect it for about six hours after the last use. Urine tests are the most commonly used, and can detect heroin up to seven days after the last use. Hair follicle tests, however, can find heroin for up to 90 days.”

Oxycodone, by contrast, can be detected in saliva for one to four days, in blood for up to 24 hours, in urine for three to four days, and in hair for up to 90 days.

Hair follicle tests offer the most accurate results as far as long-term drug use, but they can’t detect recent use. Hair follicle tests are also more expensive than urine tests.

So, what is the answer?

Research suggests that more testing, including voluntary testing, that uses multiple detection methods could provide early and essential insight.