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
Questions and concerns about urine drug screening
Why not just ask the patient? Studies have evaluated whether patient self-reporting of adherence is a feasible alternative to laboratory drug screening. Regrettably, patients have repeatedly been shown to underreport their use of both prescribed and illicit drugs.7,8
That question leads to another: Why do patients lie to their physician? It is easy to assume malicious intent, but a variety of obstacles might dissuade a patient from being fully truthful with their physician:
- Monetary gain. A small, but real, percentage of medications are diverted by patients for this reason.9
- Addiction, pseudo-addiction due to tolerance, and self-medication for psychological symptoms are clinically treatable syndromes that can lead to underreporting of prescribed and nonprescribed drug and alcohol use.
- Shame. Addiction is a highly stigmatized disease, and patients might simply be ashamed to admit that they need treatment: 13% to 38% of patients receiving chronic opioid therapy in a pain management or primary care setting have a clinically diagnosable SUD.10,11
Is consent needed to test or to share test results? Historically, UDS has been performed on patients without their consent or knowledge.12 Patients give a urine specimen to their physician for a variety of reasons; it seems easy to “add on” UDS. Evidence is clear, however, that confronting a patient about an unexpected test result can make the clinical outcome worse—often resulting in irreparable damage to the patient–physician relationship.12,13 Unless the patient is experiencing a medical emergency, guidelines unanimously recommend obtaining consent prior to testing.1,5,14
Federal law requires written permission from the patient for the physician to disclose information about alcohol or substance use, unless the information is expressly needed to provide care during a medical emergency. Substance use is highly stigmatized, and patients might—legitimately—fear that sharing their history could undermine their care.1,12,14
How frequently should a patient be tested? Experts recommend utilizing a risk-based strategy to determine the frequency of UDS.1,5,15 Validated risk-assessment questionnaires include:
- Opioid Risk Tool for Opioid Use Disorder (ORT-OUD)a
- Screener and Opioid Assessment for Patients With Pain–Revised (SOAPP-R)b
- Diagnosis, Intractability, Risk and Efficacy (DIRE)c
- Addiction Behaviors Checklist (ABC).d
Continue to: Each of these tools...
