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A 50-year-old woman with chronic pain and recurrent infections from common variable immunodeficiency presented to a new primary care physician for management of her pain medications. Her pain was related to multiple vertebral fractures due to chronic steroid use for an inflammatory polyarthritis that was not responsive to hydroxychloriquine and methotrexate. Her pain medication regimen (methadone, 20 mg [3×/d]; immediate-release morphine, 30 mg [5×/d]; gabapentin, 1200 mg [2×/d]; duloxetine, 60 mg/d; and celecoxib, 200 mg [2×/d]) helped her independently complete instrumental activities of daily living. She reported no adverse effects (eg, somnolence or constipation). A comprehensive urine drug screen using immunoassay and mass spectrometry was ordered (Table 1).
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A. The patient is taking methadone and morphine.
With the increasing opioid dependence epidemic, clinicians must monitor the use of prescription opioids to identify misuse, addiction, and diversion (ie, selling or distributing prescribed medications). Urine drug screens can confirm whether patients on chronic opioids are using prescribed drugs and abstaining from illicit substances. Occasionally, it can be difficult to interpret a result as normal or abnormal based on the metabolites found in the urine.
Mass spectrometry–based methods of detection can identify and quantify multiple drugs and metabolites simultaneously. Additionally, mass spectrometry can measure very low concentrations of excreted drugs and detect minor metabolites and impurities not quantifiable with immunoassays. Medicare midpoint reimbursements for mass spectrometry–based tests range from $158.98 to $343.07, depending on the number of drug classes being tested.1
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Corresponding Author: Geeta Nagpal, MD, Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, 251 E Huron, F5-704, Chicago, IL 60611 (firstname.lastname@example.org).
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Heiman reports serving as a member of the American Board of Internal Medicine test writing committee. No other disclosures were reported.
Additional Contribution: We thank the patient for sharing her experience and for granting permission to publish it.
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