Pain Management


Medication Monitoring with Urine Drug Testing in Pain Management

Supporting comprehensive pain management

Urine drug testing (UDT) is a useful tool in pain management that provides valuable objective information to assist in diagnostic and therapeutic decision making. Results of a UDT provide confirmation of the agreed-upon treatment plan (adherence/compliance). They can diagnose relapse or drug misuse as early as possible, and they also can be used to advocate for the patient with third-party interests.

The purpose of UDT should be explained to the patient at the initial evaluation. UDT can also enhance the relationship between healthcare professionals and patients by providing documentation of adherence to mutually agreed-upon treatment plans.

The question of whom to test is made easier by having a uniform practice policy either in a pain or primary practice that would help reduce individual stigma. Any risk of patient profiling based on racial, cultural, or other physical appearances is eliminated. Careful explanation of the purpose of testing normally allays patient concerns.

  • Monitor and support decisions about medication therapy, particularly controlled substances
  • Identify recent use of prescription medications, non-prescribed medications and illicit substances
  • Detect medications that may result in a drug-drug interaction
  • Advocate for and communicate with patients about individual treatment plans
  • Identify possible illicit drug or medication abuse, misuse or diversion
  • Clinical guidelines suggest drug testing is critical to safe and effective pain management
  • Consensus Statement of the American Academy of Pain Medicine, the American Pain Society, and the American Society


Testing should be performed for:

  • Prescribed medications
  • Non-prescribed medications that may pose a safety risk if taken with prescribed medications, and
  • Illicit substances based on
    • Patient history
    • Clinical presentation,
    • And/or community usage.

Monitoring is covered but must be based upon patient history and clinical assessment including:

  • Medication side effects or inefficacy,
  • Suspicious behaviors,
  • Self-escalation of dose,
  • Doctor shopping,
  • Indications/symptoms of illegal drug use,
  • Evidence of diversion,
  • Other clinician documented change in effect or behavioral pattern

Random Testing Frequency for Chronic Opioid Therapy

Risk StratificationFrequency
Low Risk1-2 times every 12 months
Moderate Risk1-2 times every 6 months
High Risk1-2 times every 3 months

Frequency limits may be exceeded based upon:

  • Patient response to prescribed medication suddenly changes
  • Patient side effect profile change
  • Assessment for possible drug-drug interactions
  • Sudden change in patient’s medical condition
  • Patient admission of illicit or non-prescribed controlled substance use

Confirmation testing to confirm a positive presumptive (screen) result is allowed:

When the test result is inconsistent with

  • The expected result
  • A patient’s self-report,
  • A patient’s presentation,
  • A patient’s medical history, or
  • Current prescribed medication plan
  • To verify presumptive positive using the definitive (LCMS) method
  • To confirm absence of prescribed medication
  • Following a review of clinical findings, the clinician suspects use of a substance that is inadequately detected or not detected by a presumptive (screen) test
  • To rule out an error as the cause of a negative presumptive (screen) test.

Non-Covered Services

  • Blanket orders
  • Routine reflex definitive testing when presumptive testing is performed at point of care
  • Routine standing orders for all patients in a physician’s practice
  • Reporting more than one presumptive test code per patient per date of service, regardless of the number of billing providers
  • Presumptive testing by reference laboratory prior to definitive testing without a specific physician’s order for the presumptive testing.

Custom Panel Compliance Requirements

  • The physician should request the panel
  • The physician should be the primary determinant of the test composition
  • The lab should not influence either the creation and/or composition of the panel
  • The lab must adequately document the creation of the panel using standardized forms
  • The physician should sign and date the acknowledgement
  • Should you choose not to use a custom panel, you can always select the option to perform independent presumptive and confirmatory testing. Truetox always provides, and encourages, the ability to do so