scholarly journals Importance of Urine Drug Testing in the Treatment of Chronic Noncancer Pain: Implications of Recent Medicare Policy Changes in Kentucky

2010 ◽  
Vol 2;13 (1;2) ◽  
pp. 167-186
Author(s):  
John W. John W.
Keyword(s):  
Chronic Pain ◽  
Drug Abuse ◽  
Prescription Drug ◽  
Drug Testing ◽  
Diagnosis And Treatment ◽  
Drug Misuse ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain

Background: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. Objective: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. Discussion: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. Conclusion: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse. Key words: chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

scholarly journals Urine Drug Testing in the Treatment of Chronic Noncancer Pain in a Kentucky Private Neuroscience Practice: The Potential Effect of Medicare Benefit Changes in Kentucky

2010 ◽  
Vol 2;13 (1;2) ◽  
pp. 187-194 ◽  
Author(s):  
John W. Gilbert
Keyword(s):  
Drug Abuse ◽  
Pain Management ◽  
Behavioral Health ◽  
Outcome Measures ◽  
Drug Testing ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain ◽  
Management Services

Background: Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose. Study Design: A retrospective review of urine drug testing services. Objective: To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits. Methods: An audit of services provided during 2007 was conducted using computer software. Outcome Measures: Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care. Results: Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/ or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured. Limitations: Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care. Conclusion: In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician’s toolbox, the physician’s ability to accurately diagnose and treat these patients could be impaired. Key words: Chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

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

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.

scholarly journals Shorter drug testing intervals are associated with improved drug misuse rates

2020 ◽  
Vol 16 (5) ◽  
pp. 357-373
Author(s):  
Jeff Gudin, MD ◽  
Neel Mehta, MD ◽  
F. Leland McClure, PhD ◽  
Justin K. Niles, MA ◽  
Harvey W. Kaufman, MD
Keyword(s):  
Chronic Pain ◽  
Drug Testing ◽  
Drug Misuse ◽  
Drug Adherence ◽  
Potential Drug ◽  
Serial Testing ◽  
Urine Drug Testing ◽  
Clinical Strategies ◽  
Urine Drug ◽  
Control And Prevention

Objective: The Centers for Disease Control and Prevention (CDC) recommend that clinicians prescribing opioids for chronic pain should consider at least annual urine drug testing (UDT). We evaluated whether shorter intervals for repeat UDT are associated with decreased rates of drug misuse.Design: Retrospective analysis of deidentified serial UDT and matched prescribing data.Setting: We analyzed Quest Diagnostics 2016-2017 UDT results from new patients being monitored for prescription drug adherence, in nonsubstance use disorder (SUD) treatment environments.Main Outcome Measures: Drug misuse was defined as the absence of a prescribed substance or the presence of a nonprescribed substance. Patients with ≥3 sets of the UDT results were included.Results: UDT results from 49,601 patients (148,803 specimens) were tested. Declines in misuse between the first and second UDT were highest for those tested at the shortest intervals: approximately weekly, 19 percent; monthly, 15 percent; bimonthly, 12 percent; quarterly, 9 percent; semiannually, 3 percent; misuse rates increased by 1 percent for patients tested annually. Declines in misuse were more pronounced for opioids than other drug groups. Substantial declines in positivity were noted for heroin (32 percent) and nonprescribed fentanyl (10 percent). Declines in misuse between the second and third UDT followed a similar pattern.Conclusions: UDT intervals of ≤ quarterly were associated with marked declines, but testing annually or semiannually was not associated with consistent decreases. Our findings suggest that clinical strategies that include serial testing conducted quarterly or sooner may be instrumental in decreasing drug misuse. Testing more frequently than “at least once annually” should be considered by clinicians monitoring potential drug misuse.

scholarly journals Using Urine Drug Testing to Estimate the Prevalence of Drug Use

2020 ◽  
Vol 136 (1) ◽  
pp. 47-51
Author(s):  
Benjamin H. Han ◽  
Elizabeth Mello ◽  
Ellenie Tuazon ◽  
Denise Paone
Keyword(s):  
Drug Use ◽  
Prescription Drug ◽  
Drug Testing ◽  
Population Level ◽  
Drug Misuse ◽  
Prescription Drug Misuse ◽  
Weighted Estimates ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Nyc Hanes

Objectives Estimating the prevalence of drug use in the general population is important given its potential health consequences but is challenging. Self-reported surveys on drug use have inherent limitations that underestimate drug use. We evaluated the performance of linking urine drug testing with a local, representative health examination survey in estimating the prevalence of drug use in New York City (NYC). Methods We used urine drug testing from the NYC Health and Nutrition Examination Survey (NYC HANES) to estimate the prevalence of drug use (benzodiazepines, cocaine, heroin, and opioid analgesics) among the study sample and compare the findings with self-reported responses to questions about past–12-month drug use from the same survey. Results Of 1527 respondents to NYC HANES, urine drug testing was performed on 1297 (84.9%) participants who provided urine and consented to future studies. Self-reported responses gave past–12-month weighted estimates for heroin, cocaine, or any prescription drug misuse of 13.8% (95% CI, 11.6%-16.3%), for prescription drug misuse of 9.9% (95% CI, 8.1%-12.1%), and for heroin or cocaine use of 6.1% (95% CI, 4.7%-7.9%). Urine drug testing gave past–12-month weighted estimates for any drug use of 4.3% (95% CI, 3.0%-6.0%), for use of any prescription drug of 2.8% (95% CI, 1.9%-4.1%), and for heroin or cocaine use of 2.0% (95% CI, 1.2%-3.6%). Conclusion Urine drug testing provided underestimates for the prevalence of drug use at a population level compared with self-report. Researchers should use other methods to estimate the prevalence of drug use on a population level.

scholarly journals Urine Drug Testing In Chronic Pain

2011 ◽  
Vol 3;14 (2;3) ◽  
pp. 123-143 ◽  
Author(s):  
Paul J. Christo
Keyword(s):  
Chronic Pain ◽  
Prescription Drugs ◽  
Drug Testing ◽  
Opioid Therapy ◽  
Drug Misuse ◽  
Compliance Monitoring ◽  
Chronic Opioid Therapy ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Adherence Monitoring

Therapeutic use, overuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain continue to be an issue for physicians and patients. The challenge is to eliminate or significantly curtail abuse of controlled prescription drugs while still assuring the proper treatment of those patients. Some physicians are apprehensive regarding the use of chronic opioid therapy in chronic non-cancer pain due to a perceived lack of proven evidence, the misuse of opioids, tolerance, dependence, and hyperalgesia. However, others have criticized the underuse of opioids, resulting in the undertreatment of pain. It has been the convention that federal, state, and local governments; professional associations; as well as pharmaceutical companies, physicians, accrediting bodies, medical licensure boards, and the public all share responsibility for preventing abuse of controlled prescription drugs. To overcome the critical challenge of eliminating or significantly curtailing abuse of controlled prescription drugs and at the same time assuring the appropriate treatment for those patients who can be helped by these medications, it is crucial to practice adherence or compliance monitoring of opioid therapy. Compliance monitoring has been shown to be crucial in delivering proper opioid therapy and preserving this therapy for the future. Urine drug testing (UDT) is considered one of the mainstays of adherence monitoring in conjunction with prescription monitoring programs and other screening tools, however, UDT is associated with multiple limitations secondary to potential pitfalls related to drug metabolism, reliability of the tests, and the knowledge of the pain physician. UDT is a widely available and familiar method for monitoring opioid use in chronic pain patients. UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient’s predisposition to, and patterns of, drug misuse/abuse – a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. This comprehensive review provides the role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. Key words: Controlled substances, opioids, benzodiazepines, illicit drugs, abuse, diversion, prescription monitoring programs, adherence monitoring, compliance monitoring, urine drug testing, immunoassay, chromatography, false-positives, false-negatives

scholarly journals Interpretation of Urine Drug Testing Results in Patients Using Transdermal Buprenorphine Preparations for the Treatment of Chronic Noncancer Pain: Table 1

Pain Medicine ◽  
2015 ◽  
Vol 16 (6) ◽  
pp. 1132-1136 ◽  
Author(s):  
John D. Markman ◽  
William A. Barbosa ◽  
Jennifer S. Gewandter ◽  
Maria Frazer ◽  
Shirley Rast ◽  
...  
Keyword(s):  
Drug Testing ◽  
Chronic Noncancer Pain ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Noncancer Pain

scholarly journals Urine Drug Testing of Chronic Pain Patients. II. Prevalence Patterns of Prescription Opiates and Metabolites

2010 ◽  
Vol 34 (1) ◽  
pp. 32-38 ◽  
Author(s):  
Rebecca Heltsley ◽  
Anne Zichterman ◽  
David L. Black ◽  
Beverly Cawthon ◽  
Tim Robert ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Drug Testing ◽  
Chronic Pain Patients ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Pain Patients

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

2017 ◽  
Vol 2 (20;2) ◽  
pp. s135-s145 ◽  
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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