CLINICAL BENEFITS TO URINE DRUG TESTING IN CLINICAL PRACTICE
Opioids are controlled substances that can be an adjunct for managing many patients with chronic pain; however, they have the potential for misuse or abuse.
Urine drug testing (UDT) in the clinical setting is utilized to monitor medication adherence, as an initial diagnosis for drug misuse or addiction, to encourage or reinforce healthy behavioral change, or as required for continued treatment.When used appropriately, urine drug testing can be a valuable tool to help physicians manage their patients responsibly.
UDT is commonly included in a written treatment agreement that outlines what the patient and clinician can expect of each other. This agreement describes clearly understood, well-defined descriptions of treatment boundaries (e.g., pill counts, a random or routine urine specimen for testing) and utilized when treating any patient with a chronic illness, especially chronic pain and substance abuse. The treatment agreement should be clear and reasonable. The fact that the patient and clinician have agreed to these tests suggests a positive therapeutic alliance.
Click for a sample narcotic contract to use with patients prior to initiating opioid medication management.
The frequency of testing should be determined by clinical judgment, based on a proper assessment and evaluation of the patient, and should comply with state or federal requirements. Testing frequency should be sufficient to assist in documenting the appropriate therapeutic intervention to support compliance with the agreed upon treatment plan.
CLEAR CLINICAL BENEFITS
Objective advocacy – Clinicians can use UDT as an objective means to assist in advocating for patients with family, workplace, and contested situations, such as workers’ compensation and divorce/child custody cases.
Patient Compliance Monitoring – UDT is only one of many clinical tools that are important to evaluate patient adherence to the agreed-upon treatment plan and to help assess patient stability. In these circumstances, UDT used with accurate record keeping and due care can complement other methods used by clinicians to advocate for patients.
Early Abuse Detection – Health care professionals can detect misuse or abuse of illicit or non-prescribed licit drugs by urine drug testing. Results that corroborate the patient’s self-reported use are used to assist the patient in discontinuing inappropriate drug use. UDT results that are in conflict with the patient’s self-report should be further investigated, with significant tightening of boundaries as a condition of ongoing treatment with controlled substances by limited dispensing by individual prescriptions, increased frequency of appointments, pill counts, referral to or consultation with an addiction specialist and/or other mental health care specialist. It is important to remember that drug misuse or a concurrent addictive disorder does not rule out a treatable pain problem, but requires careful evaluation and use of a treatment plan.
Prevent Diversion – Diversion is the intentional removal of a medication from legitimate distribution and dispensing for illicit sale, distribution, or use. Since many drugs are not routinely detected by all UDT, it is important to know what specific lab test will yield the result needed. Be aware of the ranges and reporting cutoff concentrations that a particular laboratory uses. The therapeutic doses of some agents might fall below the level of detection of UDT designed to deter drug misuse; even misuse of substantial quantities of some drugs may not be detected. UDT cannot diagnose diversion, which is much more complex than the presence or absence of a drug in urine. An inappropriately negative UDT result may indicate drug diversion, but it also opens up a differential diagnosis that may occur secondary to maladaptive drug taking behavior, such as bingeing, running out early of the prescribed controlled substance, cessation or change of insurance coverage, and/or monetary difficulties. One should always discuss unexpected results with the patient to determine the intention behind the abnormal behavior. Negative urine for a prescribed drug should not be interpreted as definitive evidence of criminal behavior, such as diversion.
One study among chronic pain patients receiving long-term opioid therapy found that reliance on aberrant behavior alone to trigger a UDT; reports of lost or stolen prescriptions, consumption in excess of the prescribed dosage, visits without appointments, multiple drug intolerances and allergies, frequent telephone calls, may miss a significant number of those individuals using unprescribed or illicit drugs.
Better Diagnostic Picture – Because the validity of drug users’ self-reported substance use is variable, using UDT in addition to self-report, monitoring of behavior, and other clinical tools may provide a more complete diagnostic picture. Developing a protocol of performing UDT on all patients receiving or being considered for prescription of controlled substances can help validate and destigmatize patients.
In addition to history, physical examination, contacting past providers, requesting past medical records, and querying state PMPs, performing UDT on all new patients already being treated with a controlled substance can determine whether the drug and/or its metabolite(s) are detectable in his or her urine, which would be consistent with recent use. The routine use of UDT at the initial evaluation may increase both clinician and patient acceptance of this test by normalizing the clinical context of its use. When clinicians introduce UDT as a clinical tool rather than a derogatory test, most patients will be more comfortable with this request.