By Gregory Alan Smith, M.D.

DNA testing is becoming an invaluable tool in many fields of medicine, none more important than in the management of chronic pain and addiction.

The NESP programs utilizes the Proove Biosciences DNA Opioid Risk test and Drug Metabolism test. There are several DNA testing companies that have come on the scene over the past few years but Proove started with and emphasizes testing relevant to the treatment of chronic pain and addiction. There are several possible tests but the 2 tests we normally use include:

The narcotic risk test:

This test evaluates 12 genes (alleles) involved with the serotonin receptor and transporter, dopamine 1 and 2 receptor and 1 and 2 transporter, dopamine beta hydroxylase, catecholamine methyltransferase, kappa opioid receptor, mu opioid receptor, and methylene tetrahydrofolate reductase. Each gene is classified as normal, heterozygous mutant (meaning one abnormal gene from one parent) or homozygous mutant (abnormal gene from both parents). The data is compared to the results of 10,000 controls and an “Opioid Risk Index” is determined. The control score is 12, the higher the score the higher the risk. When I began testing patients back in 2008-09 I found that the vast majority of my chronic pain patients were at medium to high risk (scores above 20). This is valuable information when considering the use of an opioid painkiller. A very high risk patient would warrant avoidance, if possible, of opioid therapy or if opioid therapy was necessary (major surgery) more frequent drug testing and closer monitoring may be indicated.

The drug metabolism test:

Specific genes produce all enzymes including the Cytochrome P450 family of enzymes that are crucial in drug metabolism. Evaluation of these genes can determine if a patient is a Poor metabolizer, Intermediate metabolizer, Normal metabolizer or Rapid metabolizer of different classes of drugs. Variants in these genes (aka alleles) determine the type of “metabolizer” a patient is. This impacts the way a patient will react to a drug such as OxyContin causing drug toxicity or lack of efficacy (ineffectiveness). This is valuable information and takes the guesswork out of introducing a new medication to a patient. Estimates range from 45-70% of patients have drug therapy problems, with most patients being poor or intermediate metabolizers that can lead to drug toxicity. This picture gets even more complicated in chronic pain and addiction where patients are often on several drugs. This can lead to worsened drug interactions and toxicity leading to morbidity and mortality. The Proove Bioscience tests 64 genes and assigns a grade of A, B, C or D to each category of drugs. A is a rapid metabolizer, B is a normal, C is a poor and D is deficient meaning no active genes producing the metabolizing enzyme for the drug, this would indicate a high risk for adverse events/side effects from drugs due to diminished drug elimination or treatment failure due to inability to convert a prodrug to an active form of a drug.

The bottom line is that DNA testing for medical purposes is the wave of the future. Although a minority of healthcare practitioners are using this tool now it will be mainstream in the coming years. We have been using this technology since late 2008.