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.
Quality Improvement Project
A clinical UDS dashboard was created by the VA Northwest Health Network and made available for use at VHA sites between 2021 and 2022. The UDS dashboard is housed on a secure, Power BI Report Server (Microsoft), with access restricted to only those with patient health data privileges. The dashboard identifies all local patients with a UDS that returned with a potential discrepancy, defined as an unexpected positive result (eg, a detected substance not recently prescribed or documented on the patient’s medication list) and/or an unexpected negative result (eg, a prescribed substance not detected). The UDS dashboard identifies these discrepancies by comparing the patient’s current medication list (both VHA and non-VHA) to their UDS results.
The UDS dashboard displays a summary of UDSs performed, unexpected negative results, unexpected positive results, and potential discrepancies. The user may also specify the laboratory type and time frame of interest to limit displayed results. The user can then view patient-specific data for any category. Among the data are the patient’s UDS results and the completion date, detected (or nondetected) substance(s), ordering clinician, associated medication(s) with last fill date and days’ supply, and whether a confirmatory test has been performed in the past year.
VABHHCS uses an extended UDS immunoassay (PROFILE-V, MEDTOX Diagnostics) that reports on 11 substances: opiates, oxycodone, buprenorphine, methadone, amphetamines, methamphetamine, barbiturates, benzodiazepines, cocaine metabolites, cannabinoids (tetrahydrocannabinol [THC]), and phencyclidine. These substances appear on the UDS dashboard. The project protocol initially included monitoring for tramadol but that was later removed because it was not available with this UDS immunoassay.
Pharmacist Process
Either the PMOP coordinator or pharmacy resident monitored the UDS dashboard weekly. Any patients identified as having a potential discrepancy were reviewed. If the discrepancy was determined to be significant, the PMOP coordinator or pharmacy resident would review the patient electronic health record. If warranted, the patient was contacted and asked about newly prescribed medications, missed and recent medication doses, and illicit substance use. Potential interventions during in-depth review included: (1) discussing future actions with the primary care clinician and/or prescriber of the controlled substance; (2) ordering a confirmatory test on the original urine sample; (3) evaluating for sources of potential false-positive results; (4) completing an updated PDMP if not performed within the past year; (5) referring patients for substance use disorder treatment or counseling; or (6) consulting the local narcotics review committee. A progress note was entered into the electronic health record with the findings and any actions taken, and an alert for the primary care clinician and/or prescriber of the controlled substance.
Implementation and Analysis
This quality improvement project spanned 16 weeks from June 2022 through September 2022. Any patient with a UDS that returned with a significant discrepancy was reviewed. The primary outcome was interventions made by the PMOP coordinator or pharmacy resident, as well as time taken to perform the in-depth review of each patient. Patient demographics were also collected. The protocol for this project was approved by the VABHHCS pharmacy and therapeutics committee and was determined to meet guidelines for a nonresearch quality improvement project.
