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.
Dido to all the above ! I am just one more VICTIM in the C D C opiate crack down. My long term pain some 15 yrs. has now left me somewhat of a vegetative state , the opiate reductions recommended by C D C HAS my doctor titrating me down monthly ,I too am a model citizen, home owner,tax payer, with no issues with law enforcement, have,by my pain management doctor done all that has been requested of me. See psychiatrist to review my records along with mental evaluation to make sure I’m not going to abuse my medical regime / psychological evaluation to assess medication abuse potential. Thru her tests and comprehensive interview result suggest that I would BENEFIT from opiate pain management and without such medication would likely suffer a decrease in his ability to manage activities of daily living. He is committed to following all prescription and medical directions and his wife acts as a support in this matter. He understands that various methods of monitoring will occur and any violation will result in the cessation of medication.
My wife ,as I write of 34 yrs Is a retired schoolteacher of 32 yrs. is more than my support, as a result of the C D C’s recommendations my pain management doctor has lowered my pain medication to the point Iam now under prescribed. I no longer walk as much ( used to walk 6miles daily) have no interest in my hobbies ( amateur lapidarest , metalsmith,gardener,traveling,antique restoration,and collecting, socializing) well that has no gone by the wayside. What’s now left with pain medication reductions is , a bitter, angry, no energy, in tears, no interest, with what /things I used to love.
At times ,thru fits of rage,I sometimes think,if I didn’t wake up one morning I would be pain free! And with CDC,s recommendations that scares the SHIT out of me, how nice it is to sit in bed crying as my wife looks on,feeling totally helpless. She too is scared,because of how well she knows me and what I’ve said in fits of rage, “FUCK IWISH I WAS DEAD” . All said, what more does a guy need to do ? This is a cry for help!
I also am further distressed ,by this stigmatization that Iam a pill popping, drug dealin,car stealing,thieving, wack job, lookin for the buzz, these people are obviously uneducated,have no care for others.it may have started with their home life, and Iam sure there are a unusual circumstances. HAVE I LOST COMPASSION FOR HUMANITY? If you had asked me a. Year ago I would have said no.
Here’s a good one. January 2018 my wife and I had planned an extended European vacation,for ten weeks, departing March ,home in mid-may 2018 . I had informed my pain management doctor and all the physicians assistants of our travels, summitted all aproperate documentations and travel itinerary ,with doctors office, and was going to need aproperate vacation prescriptions. February,again I mentioned vacation travel and need for VACATION prescriptions, then at the end of the month, I go to pick-up prescriptions and wait for it………….the doctor and PA that I had Been working with,said NO because Iam going through a CDC mandated titration and no vacation override are allowed . PERIOD! but you said ,I asked,we’ve been planning this for months,bought airline tickets,we’ve put deposits on hotels(some of where non-refundable) all said and done, Iam out over 5000.00. Sorry honey ! Needless to say ,that didn’t work out so well. Not only am I suffering but I’m now held hostage thru pain medication and the C D C
I could go on,but this is how feel !! POSTAL I now understand!
I’ve actually over heard a pharmacist say to a co-worker as I waited for my prescriptions to be filled (they didn’t see me or thought I’d left) as a man with a cane and a limp of my age walking from his car to the
pharmacist “HEAR COMES ANOTHER DRUG ADDICT. “ after I received my prescriptions . I told the girl that made the comment ,I overheard her comment . She doesn’t work there anymore
To all with LONG TERM CHRONIC PAIN WITH OPIATE THERAPY, IAM ON YOUR TEAM
Those kind of people
I’m a pain patient who doesn’t have a problem with UDT’s. I spent 12 years working undercover narcotics and understand the street. Sadly people who abuse drugs are pretty smart and will tell doctors what they want to hear.
For random drug tests to be random, pain doctors need to call patients in early for an appointment a couple times a year. If they don’t have the right number of pills when counted, it’s one of two things. Either the patient is abusing their medications or they’re under medicated….
I’m sorry to those patients who are offended with having to pee in a cup, but if that’s what it takes for legitimate pain patients to get the dose they require so they don’t commit suicide, it’s a small price to pay.
“Maximizing the Efficacy … the solution is unexpected testing during an appointment … This is a respectful approach …”
How do you think that you personally would hold up upon being on the receiving end of this thoroughly degrading and dismal draconian ode to byzantine levels of invasive pseudo psychiatric coercion – with essentially zero opportunity for any semblance of due process(?):
https://www.youtube.com/watch?v=T8qT7hlz6P0
[DSM-5, Page 485, 2013]: “Note that the word addiction is not applied as a diagnostic term in this classification, … the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.”
As a patient with irreversible, continuous, lifetime pain I was randomly called at any time of the day, any day of the week, to either report to the pain management facility for a “pill count” OR report to the hospital for a urine screen to “make sure” I was not diverting my personal, tailored dosage of prescribed medication. I did so for 14 years……without a “failed” count or test. Now after 9 years with another pain management specialist I am pill counted and urine screened evry eight weeks. Have I….after 14 years of random testing earned trust? My doctors at both facilites recognized early that I was A- in pain like I professed and B-used my medication as directed because I was self employed, desired to work and needed to work to support my wife and children. My doctors knew that I had the intellect to realize that movement, even if it was work was importnt for my “best” level of pain management and I was work oriented. Now, 23 years later at the start of 2016 I was reduced by 80 percent in my opioid medication that I had not increased or requested and increase for 9 years in 8 weeks. I was no longer “trustworthy”. I MIGHT sell the medication that has kept me enabled enough to pay recuring debt, send both of our sons to college, chance sacrificing my ability to own and operate my busines now of 37……years? REDICULOUS! I am now at the first of 2018 unemployable, lost my construction business, in pain more than I can tolerate….continupously, lost my life savings paying debt, trying CBDoils (no thc), spent lots of money on different brand of “kratom”, and now lie in the bed or sit in my recliner withour restorative sleep and have ZERO ambition to do much of anything. I am 59 years old. At what point does the doctor realize OR have the judgement to approiately, effectively treat the lifetime pain patient by his or her own skiled estimation of “why” the patient seeks pain management? NO LONGER. Dot/gov is attempting to find a blaket method of treating pain for some 10 million Americans. This absolutely idiotiic and one does NOT have to be a physician to realize this fact. We continue to take our own lives, seek street drugs which ARE plentiful and even use alcohol even if the patient has NEVER used it. As a patient for 23 years I have NEVER witnessed such an attempted and succedding method of ……more informatio gathering on American citizens. With social media, the internet , smart electronics, television, cell phones and other “secret” infor mation gathering devices I personaly am ashamed of my “elect”. I realize that not evry electe or appointed official is rotten but the CDC “guideline” for opioid prescribing physicians is simply unreasonable. Unreasonable for the patients wellness, privacy, and common sense tells the average patient that there can NOT be simply a hardline “guideline: for pain management with ZERO exceptions to effectively mange pain that is out of control. Please forgive my spelling, I commented hurredly.
You are very right, Paul. To clarify, “abuse or misuse” usually means using a drug for a purpose other than prescribed. Unfortunately, given the increasing pressure on prescribers to decrease the opioid dose or to get patients off opioids altogether, an increasing number of patients are now turning to street drugs (whether prescription opioids or illegal drugs) in order to be able to continue functioning. As a result, as opioid prescriptions have decreased, drug overdose deaths have increased. Street drugs such as heroin and fentanyl are more dangerous because the users typically don’t know the actual dose (or even drug) they are taking. And an increasing number of desperate patients are committing suicide.
A respectful approach mandates (1) discussing any unexpected result with the patient to try to understand his motivations rather than simply discharging him; and (2) considering whether to initiate other modalities (including a behavioral health referral).Improving a patient’s function is a major goal of treating chronic pain, and it may be in the patient’s best interest in terms of function to include opioids in the treatment plan.
In the linked study you state: “Opioid use disorder is characterized by signs and symptoms of compulsive, prolonged self-administration of opioids in doses exceeding a medically appropriate amount or for no legitimate medical purpose despite clinically and functionally significant impairments, such as health problems and failure to meet major social responsibilities”
In the blog post I read the following: “if a drug that was not prescribed or a drug of abuse appears in the urine, this is clear evidence of drug abuse or substance use disorder.”
We live in the reality where pain patients are woefully under treated. This it’s now possible to find patients that don’t meet any of the traits of SUD but are obviously self medicating to retain function simply to feed their families but not in any excess that is obvious abuse. How do you reconcile this situation?