Within the last four months, myself and colleagues have contributed to two publications in order to sort out various issues that need to be considered when clinicians engage in urine drug monitoring, as this has become the standard of care for patients that are regularly prescribed opioids. It is particularly important also that clinicians ordering these tests don’t over or under order them. The publications include:
- Raouf M, Bettinger JJ, Fudin J. A Practical Guide to Urine Drug Monitoring. Federal Practitioner. 2018 April; 35(4): 38-44.
- Argoff CE, Alford DP, Fudin J, Adler JA, Bair MJ, Dart RC, Gandolfi R, McCarberg BH, Stanos SP, Gudin JA, Polomano RC. Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations. Pain Medicine. 2017 Dec 1.
Dr. Jennifer Schneider recently contacted me with excellent insights to the importance of “random” v “scheduled” instances for appropriate urine drug monitoring after her consideration to the blog post she outlines below. We welcome Dr. Schneider to provide her insight and comments on this important topic as she shares this guest blog. Here’s what she had to say…
The March 23, 2018 blog, Looking for UDM Guidelines? Urine Luck indeed presented some very useful information, including
- The difference between presumptive testing (by immunoassay) which is cheaper but less precise, and definitive testing (by gas chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry) which is more specific
- The frequency of testing, which, depending on the patient’s risk for opioid misuse or addiction, can vary from once a year to multiple times
- The benefit of documenting with each urine sample the last day and hour the patient reports ingesting each of their prescribed controlled medication.
The enzyme immunoassay (EIA) test reveals only classes of drugs, such as opiates, benzodiazepines and amphetamines. Regarding opioids, the immunoassay will miss opioids that are synthetic or semisynthetic, for example fentanyl, methadone, oxycodone, oxymorphone, and buprenorphine. This is why a more accurate test is the chromatography test (GCMS or LCMS), which identifies specific molecules and their metabolites, but is very expensive compared to immunoassay.
When we know what medications are being prescribed to a patient, the UDT can show us whether a patient has indeed been taking the prescribed medication. A drug prescribed only as needed, such as an immediate-release oxycodone or morphine, may legitimately be absent from the urine if it was last taken more than 24 hours earlier. Asking the patient in advance when they last took each drug will allow us to interpret its absence in the urine more accurately; it’s great that this was mentioned in the March 23 blog. At the same time, if a drug that was not prescribed or a drug of abuse (heroin, cocaine, etc.) appears in the urine, this is clear evidence of drug abuse or substance use disorder (which is the current name for drug addiction.
To clarify, “abuse” usually means using a drug for a purpose other than prescribed, but unfortunately, given the increasing pressure prescribers are now experiencing to decrease the dose or simply to stop prescribing opioids, an increasing number of patients are now turning to street drugs (whether prescription opioids or illicit drugs) in order to be able to continue functioning.
This is why any abnormal UDT result mandates having a discussion with the patient about what’s going on and considering whether other modalities (including behavioral health referral) may be appropriate rather than simply discharging the patient. This is another whole area of misunderstanding.
Notably, it must be understood that some prescribed opioids have metabolites which are also prescribed opioids. Oxycodone is metabolized to oxymorphone, codeine to morphine, hydrocodone (and to a lesser extent morphine) to hydromorphone, so that for each of these pairs, both are expected to appear in the urine by chromatography testing. Unfortunately, it’s all too common for patients to be fired because the prescriber assumed they were getting the second opioid illicitly, which is why it’s essential to consult the lab or a knowledgeable clinician whenever an unexpected molecule appears in the urine.
The missing piece in all this is understanding the mindset of a patient who is abusing or selling drugs. As a pain and addiction specialist, I would like to describe another guideline which I believe will increase the amount of information that can be obtained from urine drug testing while at the same time is likely to decrease the cost.
If a patient knows that tomorrow or on another specific date they will be providing a urine sample, they have a window of opportunity to ensure that the sample will be “clean.” They can research how long cocaine, heroin, or other drug will stay in the body. They can avoid taking that drug long enough to minimize the chance it will appear in the urine. If they’ve been selling their prescribed drug they can take a dose a few hours before going to the provider’s office to make sure it does appear in the urine.
Current guidelines call for risk assessment of every chronic pain patient and getting a UDT more and more frequently the higher the risk appears to be. In fact, many clinicians believe that the safest approach is to obtain a UDT on every single visit. But if the patient knows in advance about the timing of the test and can prepare, there is less value to the test because less information will result. Even monthly screens are too much for the great majority of patients. That’s why even the 2016 CDC Guidelines for treatment of chronic pain don’t recommend a routine monthly screen and in fact don’t specify any particular regimen. Plus, weekly or monthly urine tests are cost prohibitive and probably unreasonable unless there is a clear reason to suspect there is an issue.
The solution? Random urine drug testing. The testing should be unexpected. In the addiction world, for example when physicians who are recovering addicts are enrolled in a physician monitoring program, they are expected to show up at the test site shortly after receiving a message to do so. This is despite the fact that it may disrupt their schedule. Why? Because if they know when they need to show up, they have time to prepare. They recognize that as known addicts they have to jump through hoops and be inconvenienced. There’s a lesson here for prescribers! What should we be asking of our patients?
What does random urine testing for pain patients look like? In my practice, I don’t believe in complicating the life of every patient on opioids by asking them to drop everything at any time and show up to provide a urine sample. They deserve to be treated with respect. Only a small minority of our pain patients are abusing or selling their drugs. We do, however, need to have a way of finding out if they’re doing this.
In my opinion, the solution is unexpected testing during an appointment, when they’re already in the office. If your risk assessment suggests twice a year testing, don’t do it specifically after 6 months; if 4 times a year, don’t schedule a UDT on the third monthly visit each time. And of course, don’t advise patients that they will need to provide a urine at the next visit. For compliant patients at low risk “twice a year plus whenever I have concerns” is a reasonable approach. This is a respectful approach which still allows you to maximize the efficacy of your testing. Testing on every visit, ordered by too many clinicians, is not the answer. Nor is a recognized pattern of timing.
As usual, we welcome your comments!
Jennifer P. Schneider, M.D. PhD is certified in Internal Medicine, Addiction Medicine, and Pain Management, and spent many years in non-interventional treatment of chronic pain. For several years she has been teaching a live national remedial/proactive 21-CME prescribing course, “Opioids, Pain Management, and Addiction” through Professional Boundaries, Inc., primarily for prescribers mandated to take such a course. She also does medicolegal consulting in this area.