Urine Drug Testing In Chronic Pain

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

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Is Urine Drug Testing a Good Idea for Patients on Chronic Opioid Therapy?

You’re Wrong, I’m Right ◽

10.1007/978-3-319-43169-7_107 ◽

2016 ◽

pp. 373-376

Author(s):

Chirag D. Shah ◽

M. Fahad Khan ◽

David S. Cheng

Keyword(s):

Drug Testing ◽

Opioid Therapy ◽

Chronic Opioid Therapy ◽

Urine Drug Testing ◽

Urine Drug

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Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic

Cancer ◽

10.1002/cncr.30240 ◽

2016 ◽

Vol 122 (23) ◽

pp. 3732-3739 ◽

Cited By ~ 32

Author(s):

Joseph A. Arthur ◽

Tonya Edwards ◽

Zhanni Lu ◽

Suresh Reddy ◽

David Hui ◽

...

Keyword(s):

Supportive Care ◽

Advanced Cancer ◽

Drug Testing ◽

Opioid Therapy ◽

Chronic Opioid Therapy ◽

Care Clinic ◽

Urine Drug Testing ◽

Urine Drug ◽

Outpatient Supportive Care

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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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Shorter drug testing intervals are associated with improved drug misuse rates

Journal of Opioid Management ◽

10.5055/jom.2020.0591 ◽

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.

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Capsule Commentary on Turner et al., Chronic Opioid Therapy Risk Reduction Initiative: Impact on Urine Drug Testing Rates and Results

Journal of General Internal Medicine ◽

10.1007/s11606-013-2675-y ◽

2013 ◽

Vol 29 (2) ◽

pp. 358-358

Author(s):

Ben A. Rich

Keyword(s):

Risk Reduction ◽

Drug Testing ◽

Opioid Therapy ◽

Chronic Opioid Therapy ◽

Urine Drug Testing ◽

Urine Drug

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Monitoring Opioid Adherence in Chronic Pain Patients: Tools, Techniques, and Utility

January 2018 - Pain Physician ◽

10.36076/ppj.2008/11/s155 ◽

2008 ◽

Vol 2s;11 (3;2s) ◽

pp. S155-S188

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Chronic Pain ◽

Drug Testing ◽

Opioid Analgesics ◽

Drug Misuse ◽

Complex Nature ◽

Current Drug ◽

Inadequate Knowledge ◽

Urine Drug ◽

Adherence Monitoring ◽

Effective Use

Opioids are important, if not essential, agents in treating certain types of chronic pain. However, the prevalence of drug misuse, abuse, and addiction has fostered considerable consternation among physicians, who may hesitate to prescribe these medications both due to concern for patients (misuse, abuse, and addiction), and fears of prosecution and/or professional sanction. Such practice may reflect 1) inadequate knowledge about patients’ susceptibility to, or current drug misuse or abuse; 2) lack of familiarity with extant assessments and/or regulations, and/or 3) an unanticipated reaction to existing guidelines, policies or laws. We posit that assessing patients’ predisposition to, and patterns of, drug misuse/abuse is a vital first step toward establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. Adherence monitoring is critical to identify patients’ prior and current drug use, establish treatment basis, and evaluate compliance, so as to avoid misuse and abuse, and ensure sound and proper pain management. This paper provides a review of the numerous monitoring approaches that have been described in the literature and addresses the benefits and limitations of these techniques and tools. The complex nature of the problem of drug misuse and abuse is discussed, and while no single monitoring technique can fully address this complex issue, we describe how multiple approaches to adherence monitoring may be employed to sustain the prudent use of opioids for the treatment of chronic pain. Key words: Opioids, adherence monitoring, drug abuse, non-compliance, misuse, addiction, urine drug testing

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