scholarly journals Laboratory-Generated Urine Toxicology Interpretations: A Mixed Methods Study

2021 ◽  
Keyword(s):  
Primary Care ◽  
Palliative Care ◽  
Drug Testing ◽  
Clinical Decision ◽  
Prescribing Behavior ◽  
Urine Toxicology ◽  
Medical Institutions ◽  
Academic Medical ◽  
Urine Drug Testing ◽  
Urine Drug

BACKGROUND: Clinicians frequently order urine drug testing (UDT) for patients on chronic opioid therapy (COT), yet often have difficulty interpreting test results accurately. OBJECTIVES: To evaluate the implementation and effectiveness of a laboratory-generated urine toxicology interpretation service for clinicians prescribing COT. STUDY DESIGN: Type II hybrid–convergent mixed methods design (implementation) and pre–post prospective cohort study with matched controls (effectiveness). SETTING: Four ambulatory sites (2 primary care, 1 pain management, 1 palliative care) within 2 US academic medical institutions. METHODS: Interpretative reports were generated by the clinical chemistry laboratory and were provided to UDT ordering providers via inbox message in the electronic health record (EHR). The Partners Institutional Review Board approved this study. Participants were primary care, pain management, and palliative care clinicians who ordered liquid chromatography-mass spectrometry UDT for COT patients in clinic. Intervention was a laboratory-generated interpretation service that provided an individualized interpretive report of UDT results based on the patient’s prescribed medications and toxicology metabolites for clinicians who received the intervention (n = 8) versus matched controls (n = 18). Implementation results included focus group and survey feedback on the interpretation service’s usability and its impact on workflow, clinical decision making, clinician-patient relationships, and interdisciplinary teamwork. Effectiveness outcomes included UDT interpretation concordance between the clinician and laboratory, documentation frequency of UDT results interpretation and communication of results to patients, and clinician prescribing behavior at follow-up. RESULTS: Among the 8 intervention clinicians (median age 58 [IQR 16.5] years; 2 women [25%]) on a Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”), 7 clinicians reported at 6 months postintervention that the interpretation service was easy to use (mean 5 [standard deviation {SD}, 0]); improved results comprehension (mean 5 [SD, 0]); and helped them interpret results more accurately (mean 5 [SD, 0]), quickly (mean 4.67 [SD, 0.52]), and confidently (mean 4.83 [SD, 0.41]). Although there were no statistically significant differences in outcomes between cohorts, clinician-laboratory interpretation concordance trended toward improvement (intervention 22/32 [68.8%] to 29/33 [87.9%] vs. control 21/25 [84%] to 23/30 [76.7%], P = 0.07) among cases with documented interpretations. LIMITATIONS: This study has a low sample size and was conducted at 2 large academic medical institutions and may not be generalizable to community settings. CONCLUSIONS: Interpretations were well received by clinicians but did not significantly improve laboratory-clinician interpretation concordance, interpretation documentation frequency, or opioid-prescribing behavior. KEY WORDS: Compliance monitoring, chronic pain, urine drug testing, opioid, liquid chromatography-tandem mass spectrometry, palliative care, primary care, substance use disorder, diagnostic error, clinical decision support

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 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

FDA/DEA/PDMP/UDT: Alphabet soup or sensible and integrated risk management?

2015 ◽  
Vol 11 (1) ◽  
Author(s):  
Steven D. Passik, PhD ◽  
Kenneth L. Kirsh, PhD ◽  
Robert K. Twillman, PhD
Keyword(s):  
Risk Management ◽  
Drug Testing ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Management Approach ◽  
Prescription Drug Monitoring Programs ◽  
Integrated Risk ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Liquid Chromatography Tandem Mass

Objective: Both prescription drug monitoring programs (PDMP) and urine drug testing (UDT) are recommended as parts of an ongoing risk management approach for controlled substance prescribing. The authors provide an editorial and commentary to discuss the unique contributions of each to promote better clinical decision making for prescribers.Design: A commentary is employed along with brief discussion comparing four states with an active PDMP in place to three states without an active PDMP as it relates back to findings on UDT in those states from a laboratory conducting liquid chromatography tandem mass spectrometry.Conclusions: The commentary focuses on the place of both tools (UDT and PDMP) in risk management efforts. The argument is made that relying on a PDMP alone would lead to clinical decisions that may miss a great deal of problematic or aberrant behaviors.

(445) Chronic opioid therapy urine drug testing in primary care: rates and predictors of aberrant results

2014 ◽  
Vol 15 (4) ◽  
pp. S87
Author(s):  
J. Turner ◽  
K. Saunders ◽  
S. Shortreed ◽  
L. LeResche ◽  
M. Von Korff
Keyword(s):  
Primary Care ◽  
Drug Testing ◽  
Opioid Therapy ◽  
Chronic Opioid Therapy ◽  
Urine Drug Testing ◽  
Urine Drug

Does the perceived accuracy of urine drug testing impact clinical decision-making?

2019 ◽  
Vol 41 (1) ◽  
pp. 85-92
Author(s):  
Barry Rosenfeld ◽  
David V. Budescu ◽  
Ying Han ◽  
Melodie Foellmi ◽  
Kenneth L. Kirsh ◽  
...  
Keyword(s):  
Decision Making ◽  
Drug Testing ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Urine Drug Testing ◽  
Urine Drug

A primer on definitive gas and liquid chromatography drug testing: What clinicians need to know

2015 ◽  
Vol 11 (1) ◽  
Author(s):  
Amadeo Pesce, PhD ◽  
Kenneth L. Kirsh, PhD ◽  
Angela Huskey, PharmD, CPE ◽  
Steven D. Passik, PhD ◽  
Catherine A. Hammett-Stabler, PhD
Keyword(s):  
Mass Spectrometry ◽  
Liquid Chromatography ◽  
Drug Testing ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Clinical Tool ◽  
Gas And Liquid Chromatography ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Compare And Contrast

Objective: To describe the differences between mass spectrometry technologies and compare and contrast them with immunoassay techniques of urine drug testing (UDT). Highlight the potential importance of the differences among these technologies for clinicians so as to allow them make decisions in their use in patient care.Methods: Review of mass spectrometry techniques, including gas chromatography, liquid chromatography, and time-of-flight techniques.Results: The potential clinical implications of these technologies stemming from their scope and accuracy are presented.Significance: UDT is an important clinical tool, though there are differences in technology and testing processes with important implications for clinical decision making. It is crucial, therefore, that clinicians have an understanding of the technologies behind the tests they order, so that their interpretation and use of results are based on an understanding of the strengths and weaknesses of the technologies used.

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