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11 Articles in Volume 13, Issue #7
Ask the Expert: Which NSAIDs are Most Selective for COX-1 and COX-2?
Chronic Pain and Depression: Sorting Out Types of Mood Disorders
Chronic Pain and Depression—Why Antidepressants Treat Both
Editor's Memo: Fibromyalgia: Time To Be a Secondary Diagnosis?
Evaluation and Comparison of Online Equianalgesic Opioid Dose Conversion Calculators
History of Pain: A Brief Overview of the 19th and 20th Centuries
Letters To the Editor
Obesity and Pain Management
Pharmaceutical Treatment of Insomnia In Intractable Pain Patients
The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain
You Ordered the Urine Drug Test: Now What?

You Ordered the Urine Drug Test: Now What?

UDT should be something you do “for our patients.” Ordering the “right test” for the “wrong purpose” can result in completely erroneous information being presented and applied to the clinical care of the patient.

Urine drug testing (UDT) can be used for a variety of purposes. Traditionally, UDT has been used in the realm of nonclinical or forensic models of collection, interpretation, and result use. In fact, with the availability of drug testing kits through the Internet and neighborhood pharmacies, there are many people who know just enough about drug testing to get themselves and others into trouble. This article will focus on the appropriate clinical use of UDT, particularly from a “patient-centered” perspective, as part of a comprehensive Risk Evaluation and Mitigation Strategy (REMS). But to be clear, UDT must not be considered as more than part of a comprehensive REMS program; it may not even be the most important part, but simply a valuable clinical tool.

Testing Strategy

Ordering the “right test” for the “wrong purpose” can result in completely erroneous information being presented and applied to the clinical care of the patient. As an example, using a sophisticated quantitative laboratory test to assess drug compliance can result in a false sense of security if the test demonstrates the presence of the prescribed drug or the potentially incorrect conclusion of drug diversion if the drug appears to be absent.1 The fact is, drug testing requires a more sophisticated and sometimes nuanced approach when applied outside the highly structured realm of forensic science. The included case examples will help to illustrate these points.

UDT either can be something we do “to our patients” or something we do “for our patients.”2 It is particularly important that those ordering the tests are clear on this point before they require their patients to participate in a drug monitoring program. If even one person on the treatment team believes that the primary goal of the test is to catch patients who are doing something wrong, it will be very difficult to convince the patient that these tests are being done for their benefit, which, after all, should be the purpose behind all patient care.

This may be doubly challenging when state guidelines appear to mandate drug testing for all patients on chronic opioid therapy.3,4 To this point, the authors would suggest the following: just because someone tells you to do something, even if for the wrong reason, doesn’t necessarily make the practice a bad thing to do. Ultimately, it all comes down to how you use the results.

So, beyond any regulatory mandate for the clinical use of UDT, why do we bother? UDT can’t tell us whether the patient is taking the medications “exactly as ordered.” It can’t tell us whether the patient is “abusing or is addicted” to the prescribed medications. It certainly can’t tell us whether the patient is diverting some or all of their medication outside of the realm of legitimate medical use. However, it can help open a dialogue between patient and caregiver, sometimes raising important discussion points that might not come up during the normal course of clinical care, around the topic of risk management. Remember, the question isn’t “Is there risk?” If the patient has a pulse, they have risk. The real question is “What is that risk – low, medium, or high?” And most importantly, “How can that risk be managed?” Equally important is the question of “By whom?”2 Not all practitioners have the experience, comfort level, or resources to manage medium- or high-risk patients. Risk management is as much about patient selection as it is about choice of drug.5

Case Example #1

A 47-year-old investment banker with a past history of problematic alcohol use returns for his first follow-up appointment for chronic low back pain, which is being treated conservatively with physical therapy alone. At this time, the physician notices that his routine UDT is unexpectedly positive by immunoassay for “opiates.” The laboratory has specifically identified morphine and codeine in the sample. To the best of your knowledge, the patient did not disclose the use of any opioid medications at his initial consultation. What would be the most reasonable next step?

Discussion

Certainly, the unexpectedly positive UDT needs to be explained. This could represent the illicit use of non-prescription opioids but it might also be something as simple as the undisclosed use of food containing poppy seeds.1,6 In this case, however, the answer is even more straightforward. The patient was prescribed Tylenol by his family dentist for a recent dental extraction. The patient had mentioned that while he used no medications regularly, he did indicate that he had recently taken Tylenol for some dental pain.

Of course, plain Tylenol (acetaminophen) cannot account for the presence of codeine/morphine in his urine drug screen, but acetaminophen with codeine can.7,8 In this case, the patient did not appreciate the importance of the distinction between plain Tylenol and Tylenol with codeine, which is a schedule III controlled substance. Checking your consultation notes, the patient did mention the use of Tylenol for dental pain, but the fact that the Tylenol was obtained by prescription was not recorded. Of course, in the time-limited context of a clinical encounter, such details often go unexplored or unrecorded. In the interest of efficiency, we’re all trained to filter out apparently extraneous information while we focus on information that seems to “fit” our diagnosis.

Key Points

  • Codeine metabolizes to morphine, so a patient legitimately using codeine as prescribed may be expected to have codeine/morphine in their urine sample.7,8
  • In the limited amount of time available to a busy clinician, getting details about medication history (either provided as samples or prescribed) by other clinicians (including nurse practitioners and dentists) may be critical to prevent an “unexpected” result from becoming an “inappropriate” result, which could adversely affect the doctor–patient relationship.
  • Educate yourself and your patients about all types of medications, both over the counter and prescription, which may influence treatment: communication is the key to a sound therapeutic relationship.2

Case Example #2

A 25-year-old man presents with chronic right leg pain, which is secondary to an open reduction with internal fixation of a compound fracture of the leg, after a motorcycle accident that occurred 9 months ago. The patient, who has multiple tattoos and body piercings, was started on sustained-release (SR) oxycodone (OxyContin) 10 mg twice daily. On the follow-up visit 2 weeks later, the dose of SR oxycodone was increased to 20 mg twice daily. A routine UDT was performed at this visit. At the third visit, the clinician noted that the patient’s urine drug screen is unexpectedly negative by immunoassay testing for “oxycodone,” which was supported by combined gas chromatography/mass spectroscopy (GC/MS) testing.

Discussion

When these results were discussed with the patient, he vigorously denied any suggestion that he was diverting his oxycodone. In fact, the patient disclosed that he had recently lost his job, resulting in his loss of healthcare insurance. As a result, he was unable to have his most recent prescription filled. The simple point here is that there can be benign explanations for apparently anomalous results, making it vitally important to talk to the patient.

Key Points

  • An “inappropriately positive/negative test result” leads to a differential, not a conclusion.1 At the end of the day, clinicians must discuss unexpected results with their patients. A clinician’s response should put the patient’s interests first, while respecting any regulatory requirements such as mandatory reporting and/or termination of opioid therapy (in this case, the patient should be required to return the unfilled paper prescription—and this fact recorded in the chart).
  • Even if termination of opioid therapy was mandated, the timeframe (immediate versus rapid taper) can often be flexible. Most importantly, the patient should be given hope, and an understanding that abandoning a molecule does not mean (necessarily) abandoning the patient (even though, a patient with criminal intent, as an example, may well abandon a prescriber who refuses to provide them with controlled substances).9
  • Criminal behavior should be the last element of the differential, not the first (and is usually the most difficult to prove).

Case Example #3

A 55-year-old stay-at-home mother of two is brought to your office by her husband. He is concerned about her use of prescription medications. The results of her last UDT are appropriately positive for prescribed medications (clonazepam 2 mg tid and hydrocodone/APAP 5 mg/500 mg 1-2 tablets up to q6h) and negative for any unprescribed or illicit drugs. The husband is particularly concerned about episodes of confusion and excessive somnolence despite inadequate analgesic effect.

During the interview, the patient seems anxious and distracted, appearing uninterested in the clinical discussion. Suddenly, the patient suffers a grand mal seizure. Appropriate steps are taken to stabilize the patient, who is later transported to the emergency room of the local hospital where she is investigated for seizure.

Discussion

In this case, the patient had not disclosed to her husband or clinician that she had been over-using her medications. Specifically, she exhibited a pattern of overuse immediately after a prescription refill, followed by rationing of her remaining medications until her next appointment. In this case, even though her urine drug screen results showed nothing of concern, the patient was, in fact, in trouble. Her seizure was ultimately attributed to acute benzodiazepine withdrawal.

Key Points

  • No single laboratory test result can substitute for the clinical judgment of an experienced clinician.
  • Any analyte that is “legitimately” present in the urine is impossible to characterize as “appropriate” in a clinical vacuum. Be careful with what you prescribe as any drug that you expect to find in the UDT result can be abused, with impunity, limiting the utility of UDT in detecting drug misuse.
  • “Borrowing from tomorrow to pay for today”10 is a common aberrant behavior used by patients to solve a real or perceived inadequate supply of medications. In this case, her excessive use of medication shortly after prescription refill resulted in an inadequate long-term daily supply of clonazepam, leaving her without adequate medication for the 5 days prior to her appointment. The neurological work-up following this seizure was completely negative, leaving the presumed cause to be benzodiazepine withdrawal.
  • If the patient’s clinical stability is at odds with any test result, including UDT, the treating clinician would be well advised to seek alternative sources of information to resolve the conflict and, where appropriate, refer the patient on for further investigation/treatment.
  • Under Health Insurance Portability and Accountability Act (HIPAA) regulations,11,12 a practitioner can “listen” to any third-party source of information, as long as there is no release of confidential information by the practitioner. The weight given to this information as to relevance and accuracy is critical. Not all information is provided free of bias or ulterior motive. To ignore information provided by family members or other interested third parties is to expose the patient and practitioner to foreseeable and potentially avoidable risk.

What Have We Learned?

Through the preceding cases, the following key points can be made.

In the first case, the practitioner is faced with unexpected information from what many would consider a scientifically objective source (UDT). In fact, this case illustrates the importance of recognizing that information exchange between the patient and practitioner is often incomplete. There is too little time to record all but the salient details of a clinical encounter. Unfortunately, it often isn’t until later when we realize that certain details can make an apparently aberrant result completely appropriate in the context of this new information.

To the patient, the dental prescription for Tylenol was of relatively little importance to his chief complaint of back pain. To the practitioner, “Tylenol” is usually inconsequential to the interpretation of a UDT result. However, what the clinician missed was the fact that the Tylenol was “prescribed” by a dentist. This information should have been clarified at the time of the initial encounter. Had the patient brought in the medication, it would have been clear that this was not plain over-the-counter Tylenol, but rather Tylenol-Codeine #3, explaining the presence of both codeine and morphine in the urine.8 Again, communication in these time-constrained clinical encounters is critical to having sufficient information to come to the proper conclusion.

In the second case, the patient’s youth and outward appearance would concern many practitioners who were contemplating the prescription of controlled substances.13 In fact, the negative immunoassay test specifically directed toward oxycodone (and confirmed by GC/MS) would concern many practitioners. Therefore, it is not difficult to imagine that the prescriptions were being filled and not taken. Fortunately, the patient had a very credible (and verifiable) explanation for his dilemma. His story becomes suspicious if he is unable to return the original prescription or a call to the pharmacy/prescription monitoring program reveals that the prescription was actually filled.

In the absence of information to the contrary, the second case simply illustrates the important principle that “you can’t judge a book by its cover.”

The third case illustrates the point that in the context of UDT, the legitimate presence of a drug in the treatment plan makes it very difficult to assess the appropriateness of that drug’s use by the patient. Further, it serves to remind us that HIPAA confidentiality regulations do not prohibit the receipt of relevant information from any third party. You can always listen to what someone has to say, even though you must be careful to not inadvertently confirm or deny private details, which would fall under a patient’s right to confidentially. Of course, how much weight you give to this information and what, if any, changes to the clinical treatment plan might be made as a result, can be challenging. That said, it is extremely unwise to ignore concerns from relevant third parties such as spouses, other family members, and collaborating health care providers when treating these often complex cases.

Summary

UDT does not have to put the patient and practitioner in conflict. When done in a patient-centered fashion—with a clear relationship between test ordered, result obtained, and clinical course taken—UDT can take its rightful place with all other clinical tests done for the benefit of the patient. No one has a greater stake in risk management than the patient; all clinical tools, including UDT, must be available for knowledgeable and caring practitioners to use in the defensible, rational, and compassionate treatment of chronic pain.10

Last updated on: August 15, 2013
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