The role of pharmacogenomics in combatting the opioid epidemic

In 2015, opioids accounted for more than two-thirds of all drug overdose deaths in the United States -- 15.6 percent more than the previous year -- and drug overdose deaths nearly tripled between 1999 and 2014.

While policy changes and education programs have been initatied to educate prescribers, opioids remain a mainstay of pain management.

One key issue is that many physicians may not be fully equipped with the scope of knowledge they need for following best practices for managing chronic pain. In fact, studies show that clinicians sometimes misunderstand urine immunoassay tests they order for patients. One study found that less than a quarter of physicians correctly answered questions about urine drug tests related to drug metabolism.

One important solution is for a greater number of physicians to work more closely on these issues with lab professionals – both in the hospital as well as other lab facilities. This level of collaboration will help phyisican to better interpret pain management tests before patients begin opioid therapy, and monitor treatment. The question for many often comes down to which type of laboratory tests to use.

Lab professionals can help physicians stay abreast of drug testing needs in their local communities, and help to identify flaws in their pain panel. They can also play a role in assessing individual patient needs and their risk of abuse for drugs.

The skyrocketing number of privately insured individuals addicted to opioids also underscores the growing importance of pharmacogenomics. PGx testing makes it possible for clinicians to prescribe the right medication at the right time for more targeted treatment.

The value of PGx for pain management
With a patient’s PGx test as a baseline reference point, a physician can better predict an adverse reaction to specific drugs. When this information is part of a patient’s medical record, these observations can emerge automatically at the point of prescription as part of the criteria for prescription decisions. In some instances, and depending upon the type of test that is initially ordered, individuals may only need to have a PGx test performed once in their life.

What’s more, a physician may choose to order one specific gene and not a full comprehensive test. As more genes are defined as playing a significant role in drug metabolism and become available for testing, physicians may also opt to order additional tests. As time passes, physicians gain a rare opportunity to view the patient’s history retroactively before prescribing or modifying prescriptions, and mitigate drug interactions. It also helps patients avoid repeated testing for chronic issues.

PGx on the rise
PGx programs are on the rise across the country. At Clinic, for example, drug-gene alerts are part of the electronic medical record system, assisting providers in delivering safer, more effective care. A large integrated healthcare system in New York also uses PGx tests in-house and implements decision-support tools within its EMR system to help doctors incorporate this information in patient care.

This healthcare system’s PGx clinic screens patients for a number of genes known to impact their ability to respond to various drugs. Approximately half of these patients came to the clinic on their own, having learned about the program in the media. The other half came through referrals — between 35 and 40 percent from psychiatrists, and the rest from primary care physicians, pain specialists and oncologists.

A number of other healthcare systems have implemented pre-emptive PGx testing programs to assess patients for variants that might impact their ability to respond to drugs they are likely to use down the road. This data is stored in the EMR, so that when doctors prescribe the drugs in the future, they are immediately alerted of the PGx information that will influence patient responses. Because physicians already factor in clinical information in order to optimize treatments for patients, the addition of PGx information could be seamlessly added, and is truly beneficial to an astute physiscian’s decision-making process.

Avoiding adverse events
A variety of medical disciplines can benefit from studying how patients metabolize medications, including cardiovascular medicine, psychiatry and pain management. Best examples are for patients who use medications to treat heart conditions, including statins to lower cholesterol and blood thinners for the prevention of blood clots.

These patients can benefit from PGx analysis aimed to determine dosing and avoid adverse events. People with certain genotypes have increased risk of life-threatening bleeds when introduced to the blood thinner warfarin or when dosages are changed. A dosing algorithm based on the patient’s genotype can potentially lower this risk.

Research has shown that maintaining steady levels of opioids contributes to pain relief, but patients metabolize pain medications at different rates. Slow metabolizers of opioids may sustain dangerously high levels of opioids in the body, resulting in adverse events. Personalized knowledge of a patient’s metabolism patterns can assist in dosing, maximizing pain control while drastically reducing risk of addiction.

PGx tests also help pain physicians to recognize that a particular patient requires a higher medication dose to experience pain relief. For example, for an ultra-rapid metabolizer, typical doses may not control pain for high metabolizers, who run the risk of being labeled abusers.

PGx drives greater drug effectiveness, with increased safety and reduced side effects. Research continues to uncover new gene variants or novel drug-gene interactions that influence whether a patient may be harmed or helped by a medication. Keeping up to date with this complex genomic information is a challenging task for clinicians, but decision-support tools and online education can help.

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