American Society of Regional Anesthesia and Pain Medicine May 2017 - 20

and tramadol. Oxycodone has an active metabolite, oxymorphone,
with significant analgesic effects. Because oxycodone depends on
CYP2D6 for clearance, patients deficient in CYP2D6 alleles could be
prone to overdose.

who is a poor metabolizer of CYP2D6, may benefit from a change
to a different opioid. In Example 2, the level of oxycodone is high,
but there is no evidence of metabolite in the urine, which may be
consistent with adulteration.

CYP3A4 is also involved in opioid metabolism. Patients taking
fentanyl or buprenorphine who are poor metabolizers of CYP3A4
would have higher than usual blood levels of these mediations.
Methadone, metabolized by CYP34A, is also metabolized by
CYP3B6*6. Lower doses should be given to patients who are
deficient in these alleles. Table 3 provides examples of clinical
consequences of opioid cytochrome P450 interactions.

Genetic testing, available through several companies, is generally
economically feasible. The test is often performed from a buccal
swab. Common available SNPs that can be tested include CYP 2D6,
2C9, 2C19, and 3A4. The test is easy to perform, and the results are
often received quickly.

URINE DRUG SCREENING
Genetic polymorphism affects urine drug screening. A patient
may state that he or she is not getting benefit from oxycodone. A
quantitative urine drug screen may show the results listed below in
Examples 1 and 2. In Example 1, the level of oxycodone is high, and
a small amount of oxymorphone appears in the urine. This patient,

20
2

The pain phenotype is a window to determine underlying
pathophysiological mechanisms and a guide for individualized
treatment options. Phenotyping can classify patients into smaller
subsets from one large disease group. It can introduce a new
standard of healthcare and help clinicians select the most
advantageous treatments to improve medical outcomes. It will
eliminate the one size fits all model that has been widely accepted
today. Phenotyping is a tool for clinical purposes that may help us

American Society of Regional Anesthesia and Pain Medicine
2017



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