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Who and When to Test: Determining Who

Urine drug testing (UDT) is recognized by Federal and State agencies and leading pain societies as a necessary component of a patient’s care when opioid medication is prescribed to treat chronic pain.

However, there is no guideline about who to test, or when.  How do you determine a patient’s risk for prescription drug misuse, abuse, or diversion?  It is an important question and the focus of the panel’s discussion in Drug Testing in Pain Management.  Dr. McCarberg is the moderator.

  • Bill H. McCarberg, MD, FABPM
    Practicing Physician, Neighborhood Healthcare in Escondido, CA
  • Humam H. Akbik, MD, FIPP
    Chief of Pain Medicine at Mercy Health in Fairfield, OH
  • Michael R. Clark, MD, MPH, MBA
    Director of the Pain Treatment Program at The Johns Hopkins Hospital in Baltimore, MD
  • Howard A. Heit, MD, FACP, FASAM
    Assistant Clinical Professor at Georgetown University School of Medicine in Arlington, VA

Risk Assessment and Patient Behavior: Is There an Infallible Method?
There is no infallible method for determining prescription drug misuse or abuse in any physician’s patient population.  Furthermore, there are no compulsory rules about predetermining a patient’s risk.

As a physician, you do have clinical judgment fine-tuned by experience, the patient’s current history, and possibly insight into their present and past behavior.

There are risk assessment models you can combine with your clinical interviewing and patient observation skills.  Risk assessment is not a new concept.

Risk Assessment Models

  • Screener and Opioid Assessment for Patients with Pain (SOAPP® or SOAPP®-R)
  • Opioid Risk Tool (ORT)
  • Diagnosis, Intractability, Risk Efficacy (DIRE)
  • Screening, Brief Intervention, and Referral to Treatment (SBIRT)
  • Current Opioid Misuse Measure (COMM®)

It is important to become familiar with available risk assessment tools, choose one that best serves your clinical needs, and then integrate it into your practice.

The Opioid Risk Tool (ORT) is a common risk assessment model.  The patient completes the form (eg, while waiting in your office).  Scoring is simple, and results provide opportunities for valuable communication between the physician and patient.

Opioid Risk Tool (ORT) Example1

  • 0-3 Low Risk
  • 4-7 Moderate Risk
  • ≥ 8 High Risk

When to Administer Urine Drug Testing?
Risk assessment tools can help you determine which patients should participate in urine drug testing.  However, UDT should be based on clinical judgment, too.  Listed below are suggestions of who should participate in UDT.

  • New patients to be started on opioids to treat chronic pain
  • New patients already taking opioids
  • Patients making a major change in treatment of chronic pain
  • Patients resisting a full evaluation (new or existing patients)
  • Patients requesting or demanding a specific drug
  • Patients exhibiting aberrant behavior
  • Patients with mental health problems
  • Patients who smoke or use other forms of nicotine


  1. Webster LR, Webster RM. Predicting Aberrant Behaviors in Opioid-Treated Patients: Preliminary Validation of the Opioid Risk Tool.  Pain Med. 2005;6(6):432-42
First published on: January 30, 2013