#44: Drug Testing is Another Tool in the Provider's Toolbox

 We have all heard the phrase, “The flavor of the moment” which can be roughly translated into one of my favorites, “People buy what is familiar”.  Covid is what is familiar to the world at this time.  Regretfully the opioid crisis which was front and center before Covid and was taking the lives of 130 Americans per day, has taken a distant back burner in many regions of this country.  One grim Covid statistic that I would bet anyone reading this is unfamiliar with is 81,003 deaths.  That is the number of people who died from drug overdoses in the 12-month period ending June 2020.  How many of the relentless talking heads mentioned this over the last year?  Stress, isolation, and economic hardship are the perfect ingredients for the optimal breeding ground for those with addiction/abuse habits. 

Our country's focus rightfully has been on the pandemic, however losing sight of other major issues, can and does, create a slippery slope none of us would like to walk.  Our toxicology division saw a decrease in the amount of testing ordered during a time we know abuse rose.   As many facilities switched to online visits no one figured out how to get a urine sample over the internet.  Without appropriate monitoring of the medications through testing many providers chose or were forced to change treatment regimens.  Although not done purposefully, this change created a negative effect on many of those with addictive tendencies.

As we dig out of the hole Covid created, our focus can once again be appropriately diversified to address issues such as addiction and abuse.  We can get back to appropriately testing those with such issues as well as pain patients who are on an opioid regimen.  It is our job in the toxicology division of our lab to assist providers who order drug testing.  As insurances continue to place more restrictions on testing it is imperative relevant testing along with accurate documentation is consistently done.  Since CMS developed the Tier system over 90 percent of insurance companies have adopted this method of determining how and what they pay for drug testing.  Although we will never tell a provider how or what to test, we can certainly guide you on the most current policies on what is considered usual and customary as far as drug testing is concerned. 

We work on the premise that drug testing is just another tool in the provider's toolbox used to assist them in making pertinent medical decisions in the treatment of their patients.  Contrary to what many think drug testing is not an attempt to “catch” the patient doing something wrong.  Used correctly the information obtained benefits both the patient and the provider in continued treatment.  We are here to help you navigate this sensitive and at times controversial, practice of drug testing.  As always we thank you for your trust in us.

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners

  

#43: The Reality of Opioid Therapy and Testing

Did you know the Sumerians in Mesopotamia were among the first people to cultivate the poppy plant around 3400BC?  Quickly this “joy plant” spread throughout the world to every major civilization in Europe and Asia and was used to treat pain and other ailments.  Opium was used throughout the world and has continued through the use of opioid therapy today.  The challenge health care providers face today is to reduce the likelihood of opioid abuse while not imposing barriers on the legitimate use of opioid medication.  Without getting too deep in the weeds, the term opioid refers to all compounds that bind to specific protein receptors.  The term opiate is used to describe opioids derived from the poppy plant (morphine and codeine).  Heroine, which is derived from morphine and oxycodone, derived from thebaine are examples of semi-synthetic opiates.  Synthetic opioids such as methadone and fentanyl are man-made. 

Most patients who are prescribed opioids for chronic pain behave differently from patients who abuse opioids and don’t ever exhibit behavior consistent with craving, loss of control, or compulsive use.  In other words, they take their meds appropriately for the intended purpose.  However, pain and addiction are not mutually exclusive, and therein lies the problem.  Many patients today are not receiving the appropriate pain care due to perceived and real risks associated with regulatory and legal scrutiny over the prescribing of controlled substances.  Many people have an immediate perception of anyone taking an opioid. 

As the pendulum of opinion regarding prescribing opioid therapy for non-cancerous pain swings back and forth between overtreatment and undertreatment, there is no disagreement when the issue of appropriate drug testing is raised.  Patients on opioid therapy should be tested for the opioid medication they are prescribed as well as any other controlled substance they may be taking.  Additionally, if they have any history of using illicit substances or misusing prescribed medications they should tested for these substances.  Testing is done to ensure the patient has the prescribed medication in their system as well as to verify they do not have any other controlled substance not prescribed.  Granted what to test and the frequency of testing can get confusing, however, ILDP can be a resource to help assist the provider in making those decisions. 

Although we would never tell a provider what to test, with appropriate risk analysis, testing the patient who has had three back surgeries and has been taking prescribed hydrocodone for a year may look a lot different than the patient whose drug test came back positive for two unprescribed medications and THC.  The frequency and amount of drugs tested for these two patients might differ considerably.  We are here to help and have a very low key unpressured approach in answering questions. 

Thank you for continuing to allow us to participate in the care of your patients.

Lance Benedict

President/CEO Industry Lab Diagnostic Partners

        

#42: Flu Season During the Covid Pandemic

With the hyper-focus on the COVID-19 virus this past year, has anyone noticed how low our Influenza numbers have been?  The infamous “twindemic” that infectious disease experts predicted for this past winter, never materialized.  From the start of the current flu season in September 2020 clinical labs in the US reported that 1,766 specimens tested positive for flu out of 931,726-a rate of just 0.2%.  Comparing this to 250,000 specimens out of 1.5 million tested during the 2019-2020 flu season the difference is drastic.  No one has ever seen a flu season this low.  According to one source, one child has died from the flu this year compared to 195 deaths last year.  Why is this?  Scientists and “experts” have come up with three likely reasons. 

-The precautions people take to avoid COVID transmissions such as masking, social distancing, and handwashing.

-Tremendous reduction in human mobility.  In other words, very little extended travel, especially international.

-Higher than normal flu vaccination rates.  Isn’t that interesting?

This is just great news, right?  Well, before you drink the cool-aid let's think through this.  The greatest distributors of the flu are children.  With the severe social restrictions we have incorporated upon our youth this past year it is indisputable that we have succeeded in reducing the flu, but at what cost?  There have been reported delays in speech and language development as well as learning social skills, like sharing, in children.  Learning to read facial expressions has been affected due to masking.  Mental health has been affected along with an increase in obesity due to inactivity. 

So, is the great reduction of flu cases along with the decrease in child deaths worth the cost?  Is there a happy medium?  I think most people would agree that life, as we knew it before COVID, has changed forever.  To what extent is to be determined.  As a person who views life as a glass half full, perhaps this is an opportunity to teach our youth, and many adults, how to thrive and be resilient in challenging times.  Although I will never find myself voting to mask forever, this pandemic has also shown the value of good hygiene. 

After the 1918 flu pandemic, our country ran into the roaring ’20s.  People congregated, mingled, hugged, and kissed.  Everything they had been deprived of during the pandemic.  They attended church, went to theaters, stadiums, and other social events.  Is the Influenza virus sitting in the bushes waiting for this to happen now?  Only time will tell. 

Thank you for trusting ILDP to be your lab.

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners 

 

#41: Antibiotic Innovators vs Superbug Resistance

 We hear about it every day in the news to the point we start to ignore the talking heads.  We know it affects someone in the US every 11 seconds and leads to one death every 15 minutes.  Yes, I am talking about antibiotic resistant infections.  Huh?  You’re telling me you don’t hear about this every minute of every day?  Since the United Nations issued a report in April of 2019 titled, No Time To Wait: Securing The Future From Drug-Resistant Infections, claiming superbugs could kill 10 million people annually by 2050, maybe we should be hearing about this daily.  Depending upon which source you read, this is 3.5 to 10 times the number of people estimated to die world-wide from COVID by the end of 2021.  Speaking of that wonderful C bug with the S on it’s chest,  COVID has actually been a contributor to overuse of antibiotics.  In New York City last year during March and April, approximately 1700 people a day were hospitalized with COVID and 70 percent of these received an antibiotic.  According to the American Journal of Health-System Pharmacy, only about 3% to 8% had bacterial co-infections at the time of admission.   This is by no means a condemnation of those front-line providers as the hyper-inflammatory syndrome caused by COVID made it difficult to differentiate between bacterial and viral infections, however, it does bring to light how easy it is to overprescribe.

 Ironically the Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR Act) is awaiting reintroduction to Congress this year.  This legislation would introduce a subscription type model for antibiotic innovators, to financially incentivize them into developing more superbug appropriate antibiotics, more quickly.  In 2019 $9.7 billion in private investment went into oncology research, compared to $132 million for antibiotic research.  This highlights where the profitability is, however severe infection and sepsis are among the most common reasons that cancer patients are admitted to intensive care units.  The CDC says 2.8 million Americans acquire serious infections caused by antibiotic-resistant bacteria each year, with 35,000 of them dying.  Without the knowledge of what specific pathogen is causing an infection many times non-specific systemic antibiotic use is or was the norm.  (None of our referring providers do that)  As a result, C. difficile has proliferated among the elderly.  CDC considers this an urgent threat as up to 15,000 people in America die from C. difficile every year.   

This antibiotic over-usage is a big problem that does not have a simple fix.  Testing for specific pathogens as well as using antibiotic resistant marker testing is one way to combat this pervasive problem.  As a molecular PCR lab, our goal is to be part of your team to help you make the best and most appropriate decisions you can in treating your patients.  This type of testing may be a paradigm shift for some of you, but we are here to make that easier.  Let us know what we can do to help you better serve your patients.  As always , we thank you for your business.  It is always appreciated.  

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners 

#40: Sars-Cov-2 Variants of Concern

On Wed March 17^th The Lancet revealed a large-scale study looking at the testing data of four million people in Denmark, which revealed that Sars-CoV-2 virus reinfection is rare.  It did, however, go on to say that adults 65 and older who tested positive for Sars-Cov-2 are more likely to be reinfected than younger people.  Those 65 and older had about 47.1 percent protection against reinfection vs. an 80 percent protection for those younger than 65. 

As of March 18^th, the more contagious B.1.1.7 UK virus has now been found in every state according to the CDC.  One peer-reviewed study published on March 10^th found that people infected with this UK variant are 32 to 104 percent more likely to die than those infected with the original strain.  The UK variant is now circulating in more than 45 countries.  The CDC projected this would be the dominant strain in the U.S. by April and it appears it is.  The South African variant (B.1.351) is now in at least 24 states and the first Brazilian variant (P.1.) is in nine states.  These are all variants of concern.  Currently, the CDC is tracking two other “variants of concern” that are in California and New York City.   Aren’t those foreign countries?  Only kidding. 

Did you know that we now have a term for people who develop long-lasting symptoms from having COVID?  They are called “long haulers”.  Don’t ask me.  According to a March 9^th study in the journal Nature Medicine these individuals are more likely to experience five or more symptoms in their first week of illness.  Early symptoms most predictive of someone being a long-hauler were fatigue, headache, breathing difficulty, a hoarse voice, and muscle pain.  Additionally, those with a higher body mass index and women were found more likely to be long-haulers.  You won’t catch me calling any woman a “long hauler”.  Symptoms long-haulers may suffer from include dizziness, insomnia, confusion, and a racing heart among others.  In another study of 1,733 hospitalized coronavirus patients, published in The Lancet, 3 out of 4 patients still suffered from at least one symptom 6 months after being released from the hospital.

According to the CDC, 95 percent of those who have died from COVID in the U.S. were over 50 years of age and eight out of ten who have died were over 65.  I am not sure these stats are 100 percent accurate as there have been many reports of the cause of death listed as COVID if the person had the virus regardless of any other disease they may have previously had.  Just saying!

More challenges await all of us as we enter the spring and summer.  Vaccines, Variants, re-opening, as well as new rules to live by.  Take one day at a time and stay the course.  We are a resilient country and we will get through this.  Thank you for trusting ILDP to perform your testing.  We appreciate it.

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners 

 

 

 

  

#39: How UTIs Have Evolved with Antibiotic Stewardship

 Dr. Boghuma Titanji, a third-year Internal Disease fellow at Emory University in Atlanta, defines Urinary Tract Infections as significant bacteriuria plus specific signs and symptoms that localize to the urinary tract.  To take it a step further she proceeds to break it down to complicated and uncomplicated UTIs.  Uncomplicated UTIs are those with the localization of signs and symptoms being limited to the bladder and below, with the patient having no other systemic symptoms.  Conversely complicated UTIs would have signs and symptoms localizing above the bladder which could lead to more serious deep seeded infections.  This difference is important when deciding upon the antibiotic to be used to treat the UTI.  Many times providers will choose not to do any labs on a “simple uncomplicated UTI”.  It may interest you to know that 60% of women who present with a UTI will have a recurrence within 6 months.  That is a high number.  Depending upon how quickly the UTI returns the quandary becomes, “Is this a recurrence or is this a relapse?” 

I pose the question, “Does it really matter?”  Standard of care dictates that if the patient returns with a UTI after three months of complete resolution of the first one, the course of treatment is the same as the first time.  If they return a third time after complete resolution it is then one should consider getting a lab test to determine what they are growing so you can be more targeted and careful with your antibiotic selection.   Why not send for a PCR test the first time to use the correct antibiotic from the beginning?  Perhaps you would be able to eliminate the recurrent episodes. 

Now that I have stirred up all kinds of sentiments, I emphasize my goal with these blogs is to make one think critically about how they treat their patients.  Additionally, I am all about antibiotic stewardship as I have mentioned before.  If there is a way to decrease the amount of antibiotics patients are given and still treat them appropriately I want to know.  One of my professors in school used the following quote frequently when we crawled into our comfortable little boxes and he wished us to think outside them, “Doctors are products of their training!”  We are taught if A then B, and many of us are guilty of hanging on to that logic throughout our careers.  The only constant thing in life is change and medicine is a reflection of that.  In the last thirty years, the treatments and tests for UTIs have evolved.  With all of the weapons (antibiotics), we have at our disposal to treat them we must have the knowledge to choose the most efficacious one.  With the use of PCR, the pathogen is defined quickly and antibiotic resistance is reported so the weapon you choose is correct the first time.  As always, ILDP appreciates your business and I personally wish you and your loved ones health and happiness. 

Thank you.

 

Lance Benedict

President/CEO Industry Lab Diagnostic Partners 

 

 

 

#38: How ILDP Assists Regarding UTI - Diagnosis and Treatment

 Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.  Providers who are top antibiotic stewards have a multi-faceted approach.  They work continuously to stay informed of the etiology of diseases and they continuously review the literature regarding use of antibiotics for specific pathogens.  Additionally, and one of the most important in my opinion, they educate their patients on appropriate use of the prescribed antibiotic and then they, or their staff, follow up with the patient during the course of treatment and after.  They also make use of the most accurate and fastest type of diagnostic testing such as PCR testing.

When to order a PCR test is also part of good stewardship to prevent unnecessary antibiotic use.  Focusing on urinary tract infections in this article, patients MUST have signs/symptoms of a UTI to order PCR testing.  Specifically fever, frequency of urination, urgency, dysuria, costovertebral or suprapubic pain, etc.  A urinalysis is not made to be a screen for a UTI infection alone.  Everything on the urinalysis is non-specific.  Okay, I already hear the gnashing of teeth and the “Yeah, but nitrites were present on the UA”.  Nitrites in the urine do suggest the presence of bacteria that have reduced nitrates to nitrites, however urethral, rectal and vaginal contaminants can cause bacteria to be present and thus produce nitrites on a UA.  Furthermore, hematuria, proteinuria, and bacteriuria found on a UA without symptoms, are not sensitive or specific enough to diagnosis a UTI. 

Recent studies show E. Coli is still responsible for the majority of UTIs, with Klebsiella pneumonia, Pseudomonas aeruginosa and Proteus mirabilis following closely behind.  Interestingly Proteus and Providencia caused more UTIs in elderly men than E. Coli.  With the discovery of a new drug resistant gene NDM-1 in E. Coli and Klebsiella, the practice of antibiotic stewardship becomes more critical.  Irrational use of antibiotics is still conducted in many parts of the world and perhaps in certain regions our own country, enabling the continued growth of more drug resistant pathogens.  In one study, E. Coli was resistant against ampicillin (92%), cotrimoxazole (80%), ciprofloxacin (62%), nitrofurantoin (47%) and amikacin (4%).  Patients who have drug resistant pathogens don’t require a history of overuse of antibiotics as the reason for acquiring them.  Environments such as nursing homes are known for the spread of these type of pathogens. 

The cat is out of the bag so to speak in regard to rampant antibiotic usage.  It is our job as a lab to assist the provider to make the appropriate decision regarding the medications they prescribe their patients.  Our  testing for drug resistance markers enables us to do this and allows us to contribute to our community antibiotic stewardship.  Please hug on your elderly family members.  As always we thank you for your business.

Lance Benedict

President/CEO Industry Lab Diagnostic Partners