Physician Renewal of Chronically Prescribed Controlled Substances Based on Urine Drug Test Results

Objective: The effect of specific urine drug testing (UDT) results on physician prescribing habits has not been well described. The primary objective was to report renewal rates of chronically prescribed controlled substances based on types of inconsistent UDT results. Methods: We conducted a retrospective chart review over a 5-month period comparing prescription renewals rates for patients with consistent versus inconsistent UDTs. Inconsistent UDTs were defined by prescribed drug not detected or the presence of heroin, cocaine, nonprescribed opioids, nonprescribed benzodiazepines, or marijuana. Results: Of the 474 UDTs reviewed, 214 (45.1%) were inconsistent. The most common findings among inconsistent UDTs, including overlapping results, were prescribed drug not detected (26.8%) and the presence of marijuana (20.7%), nonprescribed opioids (9.9%), and nonprescribed benzodiazepines (6.1%). In contrast, cocaine (5.5%) and heroin (0.4%) were less likely to be found on UDTs for this population. The relative risk (RR) of prescription renewal was 0.64 (95% CI 0.57-0.71) for inconsistent UDTs versus consistent UDTs. Within the inconsistent UDTs, the renewal rates when marijuana (79.6%) or nonprescribed opioids or benzodiazepines (63.6%) were present were much higher than when heroin or cocaine were present (0.0%; P < .001). Patients whose prescribed controlled substance was not detected had a 55.8% renewal rate. Conclusions: Prescription renewal rates were high when patient UDTs contained nonprescribed marijuana, opioids, and benzodiazepines, or when the prescribed drug was not detected. Prescription renewal rates were low when illicit drugs, such as heroin and cocaine, were detected.

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Protocol for Accuracy of Point of Care (POC) or In-Office Urine Drug Testing (Immunoassay) in Chronic Pain Patients: A Prospective Analysis of Immunoassay and Liquid Chromatography Tandem Mass Spectometry (LC/MS/MS)

January 2018 - Pain Physician ◽

10.36076/ppj.2010/13/e1 ◽

2010 ◽

Vol 1;13 (1;1) ◽

pp. E1-E22

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Diagnostic Accuracy ◽

Prescription Drugs ◽

Drug Testing ◽

Illicit Drugs ◽

Point Of Care ◽

Diagnostic Accuracy Study ◽

Controlled Substances ◽

Urine Drug Testing ◽

Urine Drug ◽

Accuracy Study

Background: Therapeutic use, overuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain continues to be an issue for physicians and patients. It has been stated that physicians, along with the public and federal, state, and local government; professional associations; and pharmaceutical companies all share responsibility for preventing abuse of controlled prescription drugs. The challenge is to eliminate or significantly curtail abuse of controlled prescription drugs while still assuring the proper treatment of those patients. A number of techniques, instruments, and tools have been described to monitor controlled substance use and abuse. Thus, multiple techniques and tools available for adherence monitoring include urine drug testing in conjunction with prescription monitoring programs and other screening tests. However, urine drug testing is associated with multiple methodological flaws. Multiple authors have provided conflicting results in relation to diagnostic accuracy with differing opinions about how to monitor adherence in a non-systematic fashion. Thus far, there have not been any studies systematically assessing the diagnostic accuracy of immunoassay with laboratory testing. Study Design: A diagnostic accuracy study of urine drug testing. Study Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To compare the information obtained by point of care (POC) or in-office urine drug testing (index test) to the information found when all drugs and analytes are tested by liquid chromatography tandem mass spectroscopy (LC/MS/MS) reference test in the same urine sample. Methods: The study is designed to include 1,000 patients with chronic pain receiving controlled substances. The primary outcome measure is the diagnostic accuracy. Patients will be tested for various controlled substances, including opioids, benzodiazepines, and illicit drugs. The diagnostic accuracy study is performed utilizing the Standards for Reporting of Diagnostic Accuracy Studies (STARD) initiative which established reporting guidelines for diagnostic accuracy studies to improve the quality of reporting. The prototypical flow diagram of diagnostic accuracy study as described by STARD will be utilized. Results: Results of diagnostic accuracy and correlation of clinical factors in relation to threshold levels, prevalence of abuse, false-positives, false-negatives, influence of other drugs, and demographic characteristics will be calculated. Limitations: The limitations include lack of availability of POC testing with lower cutoff levels. Conclusion: This article presents a protocol for a diagnostic accuracy study of urine drug testing. The protocol also will permit correlation of various clinical factors in relation to threshold levels, prevalence of abuse, false-positives, false-negatives, influence of other drugs, and demographic characteristics. Clinical Trial Registration: NCT 01052155 Key words: Controlled substances, opioids, benzodiazepines, illicit drugs, abuse, diversion, adherence monitoring, prescription monitoring programs

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Lower Cutoffs for LC-MS/MS Urine Drug Testing Indicates Better Patient Compliance

January 2018 - Pain Physician ◽

10.36076/ppj/2017.7.e1107 ◽

2017 ◽

Vol 7 (20;7) ◽

pp. E1107-E1113

Author(s):

Kevin Krock

Keyword(s):

Health Care Providers ◽

Drug Testing ◽

Illicit Drugs ◽

Patient Adherence ◽

False Negative ◽

Test Results ◽

Care Providers ◽

Urine Drug Testing ◽

Urine Drug ◽

Cutoff Levels

Background: Urine drug testing is used by health care providers to determine a patient’s compliance to their prescribed regimen and to detect non-prescribed medications and illicit drugs. However, the cutoff levels used by clinical labs are often arbitrarily set and may not reflect the urine drug concentrations of compliant patients. Objectives: Our aim was to test the hypothesis that commonly used cutoffs for many prescribed and illicit drugs were set too high, and methods using these cutoffs may yield a considerable number of false-negative results. The goals of this study were to outline the way to analyze patient results and estimate a more appropriate cutoff, develop and validate a high sensitivity analytical method capable of quantitating drugs and metabolites at lower than the commonly used cutoffs, and determine the number of true positive results that would have been missed when using the common cutoffs. Study Design: This was a retrospective study of urine specimens submitted for urine drug testing as part of the monitoring of prescription drug compliance described in chronic opioid therapy treatment guidelines. Setting: The study was set in a clinical toxicology laboratory, using specimens submitted for routine analysis by health care providers in the normal course of business. Methods: Lognormal distributions of test results were generated and fitted with a trendline to estimate the required cutoff level necessary to capture the normal distributions of each drug for the patient population study. A validated laboratory derived liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis capable of achieving the required cutoff levels was developed for each drug and/or metabolite. Results: The study shows that a lognormal distribution of patient urine test results fitted with a trendline is appropriate for estimating the required cutoff levels needed to assess medication adherence. The study showed a wide variation in the false-negative rate, ranging from 1.5% to 94.3% across a range of prescribed and illicit drugs. Limitations: The patient specimens were largely sourced from patients in either a long-term pain management program or in treatment for substance use disorder in the US. These specimens may not be representative of patients in other types of treatment or in countries with different approaches to these issues. Conclusions: The high-sensitivity method reduces false-negative results which could negatively impact patient care. Clinicians using less sensitive methods for detecting and quantifying drugs and metabolites in urine should exercise caution in assessing patient adherence using and changing the treatment plan based on those results. Key words: Urine drug testing, patient adherence, clinical toxicology, immunoassay, LC-MS, definitive drug testing, REMS, negative test results, false negative

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Reduced urinary opioid levels from pain management patients associated with marijuana use

Pain Management ◽

10.2217/pmt-2019-0017 ◽

2019 ◽

Vol 9 (5) ◽

pp. 441-447

Author(s):

Melissa M Goggin ◽

Breane J Shahriar ◽

Andy Stead ◽

Gregory C Janis

Keyword(s):

Pain Management ◽

Drug Testing ◽

Marijuana Use ◽

Potential Interaction ◽

Test Results ◽

Opioid Use ◽

Target Drug ◽

Urine Drug ◽

Urine Drug Test ◽

Lower Urinary

Aim: Marijuana use has been postulated to modulate opioid use, dependence and withdrawal. Broad target drug testing results provide a unique perspective to identify any potential interaction between marijuana use and opioid use. Materials & methods: Using a dataset of approximately 800,000 urine drug test results collected from pain management patients of a time from of multiple years, creatinine corrected opioid levels were evaluated to determine if the presence of the primary marijuana marker 11-nor-carboxy-tetrahydrocannabinol (THC-COOH) was associated with statistical differences in excreted opioid concentrations. Results & conclusion: For each of the opioids investigated (codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, fentanyl and buprenorphine), marijuana use was associated with statistically significant lower urinary opiate levels than in samples without indicators of marijuana use.

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Legal issues related to drug testing in the clinical laboratory.

Clinical Chemistry ◽

10.1093/clinchem/34.3.633 ◽

1988 ◽

Vol 34 (3) ◽

pp. 633-636 ◽

Cited By ~ 5

Author(s):

R T Chamberlain

Keyword(s):

Drug Testing ◽

Clinical Laboratory ◽

Scientific Evidence ◽

Legal Issues ◽

Third Party ◽

Urine Drug Testing ◽

Urine Drug ◽

Chain Of Custody ◽

Urine Drug Test ◽

The Many

Abstract As has been reported many times by the lay press, urine drug testing may pose some unique challenges. The clinical laboratory interested in industrial drug testing (typically known as employee drug testing) should be aware of the many challenges that may be brought on by the fact that the result may be contested in an adversarial proceeding. This is what makes the urine drug test a forensic test. It may be one piece of evidence or the only piece of evidence used in an adversarial proceeding that may decide on punitive or rehabilitative action against an employee. As a result, unique standards for governmental contract laboratories have been proposed from the National Institute on Drug Abuse, and special proficiency testing and accreditation procedures have been promoted by professional societies. These standards illustrate the sensitive nature of the results. Because the results are subject to adversarial proceedings, all parties concerned in the testing process should be aware of the legal issues surrounding urine drug testing. There are constitutional and statutory issues as well as tort issues such as negligence, defamation, invasion of privacy, battery, infliction of emotional distress, and others. Laboratories should be especially aware of these issues, since they may be brought in as a third-party defendant to a suit or brought in as a participant in gathering the evidence. The laboratory should also be aware of other legal ramifications such as chain of custody, expert testimony, and the acceptability of scientific evidence.

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Financial viability of screening for drugs of abuse

Clinical Chemistry ◽

10.1093/clinchem/41.5.805 ◽

1995 ◽

Vol 41 (5) ◽

pp. 805-808 ◽

Cited By ~ 18

Author(s):

M A Peat

Keyword(s):

Drug Testing ◽

Drugs Of Abuse ◽

The United States ◽

Economic Benefits ◽

Postal Service ◽

Test Results ◽

United States Postal Service ◽

Financial Benefits ◽

Urine Drug Testing ◽

Urine Drug

Abstract Urine drug testing is now a common practice in the American workplace; a recent survey indicated that > 90% of companies with > 5000 employees have some type of testing program. These programs have indeed reduced the rate of drug-positive test results; for example, recent data from the Federal Aviation Agency show that the rate for 1993 was 0.82% compared with 0.95% for 1992. Many corporations have stated that urine drug testing, as a component of a substance abuse policy, results in significant savings, e.g., from decreased absenteeism and turnover. The United States Postal Service recently completed a longitudinal study on the economic benefits and found that, over the average tenure of an annual intake of employees, there were savings of more than $100 million. Although this study clearly demonstrates the financial benefits of preemployment drug testing, the decision to test is not based solely on this but also on the regulatory environment and on the potential impact of a major accident attributable to the use of drugs or alcohol in the workplace.

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Systematic urine drug testing for detecting and managing opioid misuse among chronic noncancer pain patients in primary care—The HARMS Program: A retrospective chart review of 77 patients

Journal of Opioid Management ◽

10.5055/jom.2020.0581 ◽

2020 ◽

Vol 16 (4) ◽

pp. 277-282

Author(s):

Niharika Shahi, HBSc ◽

Ryan Patchett-Marble, BSc, MD, CCFP(AM)

Keyword(s):

Primary Care ◽

High Risk ◽

Drug Testing ◽

Chart Review ◽

Retrospective Chart Review ◽

Opioid Misuse ◽

Chronic Noncancer Pain ◽

Urine Drug Testing ◽

Urine Drug ◽

Noncancer Pain

The prevalence of opioid abuse has reached an epidemic level. National guidelines recommend safer opioid prescribing practices, including potentially monitoring patients with urine drug testing (UDT). There is limited research evidence surrounding the use of UDT in the context of chronic noncancer pain (CNCP). We evaluated the efficacy of systematic, randomized UDT to detect and manage opioid misuse among patients with CNCP in primary care. The Marathon Family Health Team (MFHT) designed and implemented a clinic-wide, randomized UDT program called the HARMS (High-yield Approach to Risk Mitigation and Safety) Program. This retrospective chart review includes 77 CNCP patients being prescribed opioids, who were initially stratified by their prescriber as “low-risk.” Each month, 10 percent of patients were selected for a random UDT with double testing (immunoassay and liquid chromatography-mass spectrometry). The primary outcome measure was UDT leading to a change in management plan. Of the 77 patients in the study, 55 (71 percent) completed at least one UDT during the 12-month study period. Overall, 22 patients had aberrant results. UDT led directly to changes in management in 15 of those patients. Four of those 15 patients were escalated to an addictions program, two were tapered from opioids with informed discussion, and nine were escalated to the high-risk monitoring stream. The results of this study show that in low-risk CNCP patients prescribed opioids, applying systematic UDT in a primary care setting is effective for detecting high risk behaviors and addiction, and altering management. Further research is needed with larger numbers using a prospective study design.

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Repeated Quantitative Urine Toxicology Analysis May Improve Chronic Pain Patient Compliance with Opioid Therapy

January 2018 - Pain Physician ◽

10.36076/ppj.2017.s145 ◽

2017 ◽

Vol 2 (20;2) ◽

pp. s135-s145 ◽

Cited By ~ 8

Author(s):

Nebojsa Nick Knezevic

Keyword(s):

Chronic Pain ◽

Pain Management ◽

Retrospective Analysis ◽

Drug Testing ◽

Illicit Drugs ◽

Opioid Therapy ◽

Urine Toxicology ◽

Urine Drug Testing ◽

Urine Drug ◽

Improve Compliance

Background: Even though serious efforts have been undertaken by different medical societies to reduce opioid use for treating chronic benign pain, many Americans continue to seek pain relief through opioid consumption. Assuring compliance of these patients may be a difficult aspect of proper management even with regular behavioral monitoring. Objective: The purpose of this study was to accurately assess the compliance of chronic opioidconsuming patients in an outpatient setting and evaluate if utilizing repeated urine drug testing (UDT) could improve compliance. Study Design: Retrospective analysis of prospectively collected data. Setting: Outpatient pain management clinic. Methods: After Institutional Review Board (IRB) approval, a retrospective analysis of data for 500 patients was conducted. We included patients who were aged 18 years and older who were treated with opioid analgesic medication for chronic pain. Patients were asked to provide supervised urine toxicology specimens during their regular clinic visits, and were asked to do so without prior notification. The specimens were sent to an external laboratory for quantitative testing using liquid chromatography-tandem mass spectrometry. Results: Three hundred and eighty-six (77.2%) patients were compliant with prescribed medications and did not use any illicit drugs or undeclared medications. Forty-one (8.2%) patients tested positive for opioid medication(s) that were not prescribed in our clinic; 8 (1.6%) of the patients were positive for medication that was not prescribed by any physician and was not present in the Illinois Prescription Monitoring Program; 5 (1%) patients tested negative for prescribed opioids; and 60 (12%) patients were positive for illicit drugs (8.6% marijuana, 3.2% cocaine, 0.2% heroin). Repeated UDTs following education and disclosure, showed 49 of the 77 patients (63.6%) had improved compliance. Limitations: This was a single-site study and we normalized concentrations of opioids in urine with creatinine levels while specific gravity normalization was not used. Conclusions: Our results showed that repeated UDT can improve compliance of patients on opioid medications and can improve overall pain management. We believe UDT testing should be used as an important adjunctive tool to help guide clinical decision-making regarding opioid therapy, potentially increasing future quality of care. Key words: Urine toxicology analysis, chronic pain, opioids, compliance, pain management, urine drug testing, urine drug screening

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Specimen validity testing in urine drug monitoring of medications and illicit drugs: Clinical implications

Journal of Opioid Management ◽

10.5055/jom.2015.0252 ◽

2015 ◽

Vol 11 (1) ◽

Cited By ~ 4

Author(s):

Kenneth L. Kirsh, PhD ◽

Paul J. Christo, MD, MBA ◽

Howard Heit, MD ◽

Katherine Steffel, PharmD ◽

Steven D. Passik, PhD

Keyword(s):

Drug Testing ◽

Illicit Drugs ◽

Patient Adherence ◽

Adherence Behavior ◽

Medical Problems ◽

Clinical Role ◽

Validity Testing ◽

Therapeutic Decisions ◽

Urine Drug Testing ◽

Urine Drug

Objective: To discuss the importance of specimen validity testing (SVT) in urine drug testing (UDT) and the clinical role it plays in identifying efforts to subvert the UDT process.Methods: A discussion of the clinical impact of SVT is presented.Results: A discussion of pH, specific gravity, creatinine, and oxidation for monitoring the adulteration of UDT samples is presented along with the clinical significance of such tests.Significance: SVT has a significant place in healthcare efforts to measure patient adherence, behavior, and honesty in communication with clinicians. SVT is typically ordered by treating clinicians who use the results to make therapeutic decisions regarding specific medical problems of their patient, including those related to medication and illicit drug use. In the absence of SVT, a healthcare provider may fail to identify a patient's adulteration of their urine sample in an attempt at deceiving the provider. Moreover, the presence of some underlying medical conditions may obfuscate the UDT results.

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Patterns of Marijuana Use in a 6-Month Pain Management Sample in the United States

Substance Abuse Research and Treatment ◽

10.1177/1178221817724783 ◽

2017 ◽

Vol 11 ◽

pp. 117822181772478 ◽

Cited By ~ 1

Author(s):

Hope M Smiley-McDonald ◽

Katherine N Moore ◽

David C Heller ◽

Jeri D Ropero-Miller ◽

Gregory L McIntire ◽

...

Keyword(s):

Pain Management ◽

Drug Use ◽

Prescription Drugs ◽

Drug Testing ◽

Illicit Drugs ◽

Marijuana Use ◽

The United States ◽

Prescription Drug Use ◽

Urine Drug Testing ◽

Urine Drug

This study is a 6-month retrospective analysis of urine drug testing (UDT) data from a pain management population among specimens with clinician-ordered marijuana testing (N = 194 809). Descriptive statistics about the specimen positivity of clinician-ordered marijuana UDT are provided as well as other drug positivity. Specimens from men and adults aged 18 to 34 years had the highest prevalence rates of marijuana positivity. The prevalence of past-month marijuana use among a comparative national population was lower than the prevalence of positive marijuana tests in the UDT specimens by all characteristics. Among the specimens tested for illicit drugs and marijuana, 4.0% were positive for amphetamine, 2.8% were positive for cocaine, and 0.9% were positive for heroin. The most common prescription drugs listed were opioids (64.7%), benzodiazepines (20.5%), and antidepressants (19.9%). In sum, the findings reflect previous research showing high rates of marijuana use, illicit drug use, and prescription drug use in a pain management population.

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Illicit Drug Use in the Pain Patient Population Decreases with Continued Drug Testing

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/189 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. 189-193 ◽

Cited By ~ 2

Author(s):

Amadeo Pesce

Keyword(s):

Drug Use ◽

Drug Testing ◽

Illicit Drugs ◽

Illicit Drug ◽

Illicit Drug Use ◽

Pain Patient ◽

Spearman Correlation ◽

Urine Drug Testing ◽

Urine Drug ◽

Pain Patients

Background: A major concern of physicians treating pain patients with chronic opioid therapy and similar drugs is determining whether the patients are also using illicit drugs. This is commonly determined by urine drug testing (UDT). However, there are few studies on whether or not monitoring patients by this technique decreases illicit drug use. Objective: To determine if the presence of illicit drugs decreases over a number of physician visits where UDT was performed. Method: The method involved a retrospective study of tests for the illicit drugs marijuana, cocaine, methamphetamine, ecstacy (MDMA) phencyclidine (PCP) and the heroin metabolite, 6-acetylmorphine as confirmed by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS). A database of 150,000 patient visits was examined for the presence of any of these 6 drugs. Results: A total of 87,000 patients were initially tested. The number of patients who were repeatedly tested decreased over time. The percentage of patients positive for any of these illicit drugs decreased from 23% to 9% after 14 visits where UDT was performed. When graphed there was a trend to decreasing use. The Spearman correlation = -0.88, P < 0.0001. The major illicit drug was marijuana. When this was removed from the analysis, there was an even greater correlation with decreased illicit drug use. Spearman correlation = -0.92 (P < 0.0001) using a weighted correlation. Limitation: Patients continuing to use illicit drugs might be dismissed from practices thus biasing the study towards illicit drug avoidance. Conclusion: Continued UDT might decrease illicit drug use among pain patients. Key words: Pain patients, UDT, urine drug testing, LC-MS/MS, illicit drugs, decrease drug use

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