Urine drug screening: A guide to monitoring Tx with controlled substances
Avoid error by ordering the appropriate test at a risk-based frequency. Be alert to sources of false-positives and adulteration. Be careful not to overreact to unexpected results.
PRACTICE RECOMMENDATIONS
› Consider developing a risk-based urine drug testing protocol for all patients who are on chronic opioid therapy. C
› Consider urine drug testing to augment a thorough history when identifying and offering treatment to patients with a substance use disorder. A
› Do not change your management plan based on results of a single screening urine test. Revisit unexpected positive or negative results with a thorough history or confirmatory testing. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Each of these tools takes less than 5 minutes to administer and can be used by a primary care physician to objectively quantify the risk of prescribing; there is no evidence for the use of 1 of these screeners over the others.15 It is recommended that you choose a questionnaire that works for you and incorporate the risk assessment into prescribing any high-risk medication.1,5,15
Once you have completed an initial risk assessment, the frequency of UDS can be based on ongoing assessment that incorporates baseline testing, patient self-reporting, toxicology results, behavioral monitoring, and state database monitoring through a prescription drug monitoring program. Annual screening is appropriate in low-risk patients; moderate-risk patients should be screened twice a year, and high-risk patients should be screened at least every 4 months (FIGURE).15
Many state and federal agencies, health systems, employers, and insurers mandate the frequency of testing through guidelines or legislation. These regulations often are inconsistent with the newest medical evidence.15 Consult local guidelines and review the medical evidence and consensus recommendations on UDS.
What are the cost considerations in providing UDS? Insurers have been billed as much as $4000 for definitive chromatography testing (described later).3 This has led to insurance fraud, when drug-testing practices with a financial interest routinely use large and expensive test panels, test too frequently, or unnecessarily send for confirmatory or quantitative analysis of all positive tests.3,14 Often, insurers refuse to pay for unnecessary testing, leaving patients with significant indebtedness.3,14 Take time to review the evidence and consensus recommendations on UDS to avoid waste, potential accusations of fraud, and financial burden on your patients.
Urine toxicology for addiction treatment
UDS protocols in addiction settings are often different from those in which a controlled substance is being prescribed.
Continue to: Routine and random testing
