A Pharmacist-Led Process to Monitor Discrepant Urine Drug Screen Results
Background: A urine drug screen (UDS) is a common risk-mitigation strategy tool for prescribing controlled substances, particularly opioids. Due to their complexity, UDS results can be misinterpreted and thereby have profound impacts on the patient-clinician relationship. From 2021 to 2022, a clinical dashboard to review potentially discrepant UDS results—based on a comparison of the results to the patient’s medication list—was made available by the Veterans Health Administration.
Methods: This quality improvement project implemented a process for weekly clinical pharmacist reviews of the UDS dashboard. Significant discrepant UDS results were reviewed in depth. From June 2022 through September 2022, 700 UDSs were performed and 60 patients had significant discrepancies that warranted in-depth review.
Results: Pharmacist interventions during the review included 39 collaborations with medication prescribers to discuss follow up (65%), 25 queries to a prescription drug monitoring program (42%), and 9 confirmatory UDS on the original sample (15%). In-depth reviews were required for about 4 patients weekly, with a mean length of 14 minutes.
Conclusions: A pharmacist-led process to monitor discrepant UDS results led to opportunities for collaboration with prescribers and positively impacted confirmatory testing at a rural veterans affairs health system.
Urine drug screen (UDS) monitoring is a common risk-mitigation strategy tool for prescribing controlled substances.1-3 Not only is UDS monitoring highlighted by clinical practice guidelines for opioid prescribing for chronic pain,1,2 it has also been suggested as best practice for benzodiazepines3 and a consideration for other controlled substances. Monitoring UDSs helps confirm adherence to the prescribed treatment regimen while also screening for substance use that may increase patient risk.
UDS results can be complex and have profound implications for the patient’s treatment plan. Drug metabolites for opioids are particularly complicated; for example, synthetic and semisynthetic opioids are not detected on routine opiate immunoassays.4 This may lead a clinician to falsely assume the patient is not taking their fentanyl or tramadol medication as directed—or potentially even diverting—in the face of a negative opiate result.5 Routine UDSs are also subject to the pitfall of false-positive results due to coprescribed medications; for example, bupropion can lead to a false-positive amphetamine result, whereas sertraline can lead to a false-positive benzodiazepine result.6 Retrospective reviews of clinician behavior surrounding UDS interpretation have demonstrated knowledge gaps and inconsistent communication practices with patients.7,8
Given the complexity of UDS interpretation and its close relationship with medications, pharmacists are positioned to play an important role in the process. Pharmacists are embedded in pain-management teams and involved in prescription drug monitoring programs (PDMPs) for many health systems. The Veterans Health Administration (VHA) has supported the hiring of pain management, opioid safety, and PDMP coordinators (PMOP) at its facilities to provide clinical pain-management guidance, support national initiatives, and uphold legislative requirements.9 In many facilities, a pharmacist is hired specifically for these positions.
Clinical dashboards have been used by pharmacists in a variety of settings.10-13 They allow clinicians at a broad level to target interventions needed across a patient population, then produce a list of actionable patients to facilitate delivery of that intervention on an individual level.13 Between 2021 and 2022, a clinical dashboard to review potentially discrepant UDS results was made available for use at US Department of Veterans Affairs (VA) medical centers. Evidence exists in primary and specialty care settings that implementation of an opioid-prescribing clinical dashboard improves completion rates of risk-mitigation strategies such as UDS and opioid treatment agreements.14,15 To our knowledge there is no published research on the use and outcomes of a clinical dashboard that allows users to efficiently review discrepant UDS results when compared to a list of currently prescribed medications.
Given the availability of the UDS dashboard at the VA Black Hills Health Care System (VABHHCS) in South Dakota and the hiring of a PMOP coordinator pharmacist, the aim of this quality improvement project was 2-fold: to implement a pharmacist-led process to monitor the UDS dashboard for potentially discrepant results and to describe the quantity and types of interventions made by the clinical pharmacist leading this process.
