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Expert Panel Report on Urine Drug Monitoring for At-Risk Chronic Pain Patients

December 12, 2017
The consensus guidelines address the how, when, and for whom to employ urine monitoring for patients receiving an opioid prescription in the primary care setting.

With Lynn Webster, MD 

Given that opioids have been prescribed to nearly one in three patients who present to their primary care practitioner (PCP) for relief from a chronic pain condition,1 the foremost question remains—which of these patients may be a risk for the unintended consequences of misuse or an opioid use disorder, yet don’t readily report misuse of prescription pain medications, alcohol, or use of illegally obtained medications.2

As primary care practitioners (PCPs) face the ongoing challenges inherent in treating patients for chronic pain, the need to consider periodic urine drug monitoring (UDM) for patients likely to be on long-term opioid therapy remains a challenge. However, there are no current guidelines that address the specific concerns of which patients to test, which substances to test for, how often to test, and how to act on the results.2

 “We felt the time was right to provide a coherent, practical recommendation on handling urine monitoring that would be of value in the primary care setting and one that all practitioners could refer to and use,”2 said Lynn R. Webster, MD, senior author and past president of the American Academy of Pain Medicine.

“However, we didn’t want to prescribe a process as much as remove the noise (ie, disparities in care), to provide a guide based on our review of the literature and our collective clinical judgment of the panel members to inform practice,” Dr. Webster told Practical Pain Management

Overview of Recommendations for Urine Drug Monitoring

While evidence of efficacy in using UDM to prevent or uncover an opioid use disorder exists, there are many opinions, views, and positions with regard to opioid monitoring circulating.2 In addition, the last formal recommendations regarding urine drug monitoring for opioids in the treatment of chronic pain were issued in 2012.3

“Given the lack of common ground on how to approach and interpret urine test results, a panel of experts across pain management convened to address the variability so that primary care practitioners would have a simple, specific guideline that is implementable in the office setting,”2 said Dr. Webster who is vice president of scientific affairs at PRA Health Sciences in Raleigh, North Carolina.

The term, urine drug monitoring, was selected to reflect an ongoing process, rather than a single test or screening event, and was intended to convey a non-punitive method of shared monitoring.2

Urinary drug monitoring is advised for patients determined to be at moderate to high risk of opioid use disorder. UDM should be administered prior to prescribing an opioid for relief of chronic pain, and again during the year depending upon assessed risk level, as follows:

  • At High risk—three or more times per year
  • Moderate risk— retested on two or more occasions per year
  • Low risk—at least once annually

Assessing level of patient risk for abuse prescription opioids (ie, opioid risk stratification) should be based on patient history, including psychiatric stability, prior diagnosis of opioid or substance use disorder, and results of validated risk assessment tools.2

The most recent guidelines proposed less rigorous urine testing at least once yearly for every patient irrespective of risk, every six months to two years for those at low-risk, one to three times for those deemed at moderate risk, and at least two to four times annually for high-risk patients.4-6 Interestingly, there was no accounting for risk in the Centers for Disease Control and Prevention Guidelines for Prescribing Opioids for Chronic Pain because of the inaccuracy of existing predictive tools.4

Process for Devising Consensus Recommendations

The panel included a range of experts, including specialists in pain management and addiction, as well as primary care.2 The panelists reviewed the current literature and current management guidelines, then applied their clinical experiences with urine drug monitoring in order to arrive at these consensus recommendations.

Often when prescribing opioids and monitoring patient use, there is an inherent distrust of the clinician, Dr. Webster said, While implementing a urine monitoring protocol may not mend the trust, per se, the focus should be about how the physician introduces the process of opioid monitoring, and a sound rationale for the frequency of testing to be imposed.

“Employing urine drug monitoring alone won’t help develop or lose trust, rather how physicians communicate with their patients will have the most impact on building and maintaining confidence in the process,” said Dr. Webster, which should be an essential step ahead of writing a prescription for an opioid to address a patient’s chronic pain.

Establishing an Opioid Risk Assessment Protocol

Urine drug monitoring should become part of a comprehensive risk assessment program in moderate to high-risk patients was appropriate, which may improve patient adherence to and better outcomes, and maintain a good physician-patient relationship.2

“Clinicians are encouraged to discuss the plan for UDM just as they would for any other procedures,” said Dr. Webster. However, it is crucial that the discussion focus on safety and concerns of the risks associated with long-term use of opioid medications that should include the reason for frequency of monitoring, how frequency was determined, possible laboratory errors including evidence of tampering, anomalies, and effects of drug-drug interactions.2

Key points from consensus recommendations:2

  • Use definitive testing (rather than an in-office assay) as the preferred method for establishing a baseline assessment of opioid use
  • Determine the frequency of monitoring based on assessed risk of each patient who seeks treatment for chronic pain prior to issuing an opioid prescription to include:

o   physical exam

o   validated assessment tools to determine medication/ substance use history, and mental health status

o   history of opioid use/misuse from prior prescribers

o   at risk for respiratory depression/overdose

o   check PDMPs and any prior UDM results

  • Perform baseline UDM in every patient prescribed an opioid for pain relief, and conduct ongoing monitoring as long as opioid is prescribed

The recommendations introduced the topic of screens for two commonly related substances—alcohol and cannabis, but didn’t go into detail:

Alcohol: To differentiate between alcoholic beverages and alcohol-containing products such as mouthwash, and antibacterial sanitizer products, practitioners are advised to use the National Insitute on Alcohol Abuse and Alcoholism self-administered, single question screening (SISQ).8  For example, ask “How many times in the past year have you had (five or more drinks [men], four or more drinks [women]) in a day?”

Cannabis: This report offered no formal recommendation with regard to screening other than to leave the decision on screening for cannabis use to individual prescribers to be guided by local laws and/or insurer requirements since clinical implications of a positive finding remain ambiguous.2

For practitioners who choose to screen or are mandated by an insurer or local laws, the panel recommended using a validated SISQ for drugs including cannabis.1  Practitioners may ask, for example, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”)9

“There are two forces—health insurers and time to results—that may influence the method of urine testing that practitioners may have to use,” Dr. Webster told Practical Pain Management, “more sophisticated tests are significantly more expensive and may not be covered unless a point of service assay is done first to demonstrate a positive finding, despite a 50% accuracy.”

For some payers and physicians, this in-office test may be sufficient, but absence or presence of opioids at levels of concern still will need to be confirmed. As such, the consensus guidelines offer a balance between real world situations and insurance demands, he said.

Negative Consequences of Opioid Use Monitoring

There is an inherent concern that patients may not return for a follow-up visit when monitoring is presented during the initial visit, particularly among patients who have had a negative urine test in the past, lessening trust with the clinician.

“Practitioners are reminded that a breakdown in a good rapport with the patient may be mitigated by providing a credible rationale for urine monitoring, which will also become less of a stigma as it becomes general practice nationwide,” Dr. Webster said.

According to the consensus recommendations, the panel suggested that any concerns about interpretation of UDM findings should be directed to a toxicology expert or a clinical pathologist.2


More on this topic in the PPM/Quest Clinical Drug Monitoring online resource guide.

Last updated on: October 11, 2018
Continue Reading:
Survey: Many Doctors Confused About Opioid Abuse

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