The leader of a multidisciplinary addiction medicine and behavioral health practice in Maryland vividly recalls a patient case that demonstrated the value of knowing early on how someone is likely to respond to a medication treatment.
J. Ramsey Farah, MD's patient had been addicted to opioids long-term and was very gradually weaned off methadone after a successful course of treatment. It was recommended that the patient begin monthly injections of Vivitrol (injectable naltrexone), and Farah's practice gave him a 10-mg oral dose of naltrexone to verify tolerance. The man immediately developed a severe reaction from one dose, requiring a 10-day hospital stay for neurological complications.
“Only 3 of 10,000 patients would have this effect,” says Farah.
The Maryland physician is among a growing group of doctors making greater use of predictive testing to identify patients' risk for tolerance or misuse of the medications prescribed to them. Addiction Professional recently interviewed two physicians who are using proprietary genetic testing technology developed by Southern California-based Proove Biosciences.
Farah, who is board-certified in addiction medicine, says that with the various options now available for medication-assisted treatment in his field, it is important to be able to predict the likelihood of a particular medication's effectiveness—or potential risks—for the individual.
“If I hit it right from the get-go, I'm a hero,” Farah says.
Range of applications
Karim Abdollahi, MD, an orthopedic surgeon practicing out of Laguna Beach, Calif., has been using Proove's predictive testing since last September. For patients of his who will need painkillers after a planned surgery, the tests can help him determine in advance which opioid or non-opioid medications might be the most logical choice for the individual.
But Abdollahi adds that with a full panel available through the testing, some of the findings also can inform decision-making for a patient's other healthcare providers.
He says that the patients whose insurance covers the testing receive it as soon as they come through the door of his practice, Advanced Orthopaedic Specialists. Besides payment barriers, there sometimes will be resistance from patients who hear the term “genetic testing” and believe that somehow the privacy of their health information will end up being compromised. “They think the information might be used in some weird way,” Abdollahi says.
Abdollahi recalls the case of a patient who was found to be responsive only to fentanyl among all available pain medications (a challenge, since fentanyl is not widely available to patients outside of hospital operating room settings). The patient was preparing to undergo a shoulder procedure, and Abdollahi had wanted to make fentanyl available to him immediately post-surgery. But the patient's pain management specialist said he was legally bound to try him on another drug first before pursuing fentanyl. The other drug ultimately wasn't effective, and the patient received access to fentanyl later.
Information for future
Farah's 30-member practice in Hagerstown, Md., Phoenix Health Center, often sees patients who have suffered the consequences of failed experiences in pain clinics or family practices. Knowing in advance if someone will or won't be a responder to a certain medication can save precious time and resources for patients with multiple problems, Farah indicates.
“We need to look at precision medicine not only for what it can do for our patients today, but that there is enough DNA saved so that if new [pharmaceutical] products come in, we can test against them,” he says.
The CEO of Proove, a company founded in 2009, says the development of technologies such as this seeks to transform physician decision-making, acknowledging that genetics are a component but not the be-all and end-all of patient response.
“Genetics have influence, and you need to analyze this, or you will miss something that should inform treatment,” says Proove CEO Brian Meshkin. “A leading cost [in medicine] is the cost of failure.”