American Society of Regional Anesthesia and Pain Medicine May 2017 - 21
Example 1: Patient prescribed oxycodone who is poor metabolizer of CYP2D6.
Test
Flag results
Measured results
Unit
Reference value
Confirmation opioids
positive
ng/ml
<100
Codeine
negative
ng/ml
<100
Hydrocodone
negative
ng/ml
<100
Hydromorphone
negative
ng/ml
<100
Morphine
negative
ng/ml
<100
Oxycodone
positive
20,240
ng/ml
<100
Oxymorphone
positive
964
ng/ml
<100
Example 2: Urine drug screen consistent with adulteration.
Test
Flag results
Measured results
Unit
Reference value
Confirmation opioids
positive
ng/ml
<100
Codeine
negative
ng/ml
<100
Hydrocodone
negative
ng/ml
<100
Hydromorphone
negative
ng/ml
<100
Morphine
negative
ng/ml
<100
Oxycodone
positive
63,267
ng/ml
<100
Oxymorphone
negative
0
ng/ml
<100
improve pain management. We can classify patients with similar
pain etiology based on pain related sensory abnormalities-
otherwise known as "sensory profiling"-and then direct
management based on this classification. It is difficult and costly
to genotype a large number of patients, but phenotyping with
large patient cohorts is possible. Obtaining the sensory profile of
a patient may reflect an underlying mechanism or combination of
mechanisms influencing pain. Once determined, medication trials
would follow. Responses based on sensory profile and certain pain
descriptors would lead to targeted treatment options. Detailed
phenotypic data gathering is necessary to understand the factors
that ultimately define a phenotype. It is something we do every day
in clinical practice while gathering information on demographics,
pain history, physical examination, and investigations.
An example of clinical phenotyping is the UPOINT (Urinary,
Psychosocial, Organ Specific, Infection, Neurologic, and Tenderness
of Skeletal Muscles) system for a patient with urological chronic
pelvic pain.8 Instead of including all patients under one diagnosis,
patients are classified into subtypes and managed according to
the classification system. Based on the best available evidence,
clinical phenotyping of patients directs management of individual
phenotypes based on best available evidence. Multimodal therapy
can then be selected as indicated by phenotype domains in the
individual patient.
Another example of clinical phenotyping is a study conducted in
patients with diabetic peripheral neuropathy (DPN), postherpetic
neuralgia (PHN), radicular (neuropathic), or axial (nonradicular)
low back pain (LBP). The investigators conducted 16 interview
questions and 23 bedside examinations. They assessed symptoms
and signs of 130 patients and performed a cluster analysis that
revealed association patterns that characterized six subgroups
with neuropathic pain and two subgroups with non neuropathic
pain. There were eight subgroups of patients (clusters C1 to C8).
Patients with DPN, PHN, and radicular LBP were distributed across
the clusters C1 to C6, patients with axial LBP formed the clusters
C7 and C8. When the investigators used classification tree analysis
to determine the minimum number of interview questions and
physical tests that would assign patients to clusters, interview
questions were narrowed down to 6 and physical tests to 10. They
then evaluated the diagnostic usefulness for LBP. Sensitivity and
American Society of Regional Anesthesia and Pain Medicine
2017
21
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