Urine drug screening: A guide to monitoring Tx with controlled substances

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doi:10.12788/jfp.0168

Applied Evidence

Urine drug screening: A guide to monitoring Tx with controlled substances

J Fam Pract. 2021 April;70(3):112-120 | 10.12788/jfp.0168

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References

1. TAP 32: Clinical drug testing in primary care. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Department of Health & Human Services; 2012. Technical Assistance Publication (TAP) 32; HHS Publication No. (SMA) 12-4668. 2012. Accessed March 19, 2021. https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4668.pdf

2. Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376. https://doi.org/10.1016/j.drugalcdep.2018.05.033

3. Segal, David. In pursuit of liquid gold. The New York Times. December 27, 2017. Accessed March 19, 2021. https://nyti.ms/2E2GTOU

4. Ceasar R, Chang J, Zamora K, et al. Primary care providers’ experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings. Subst Abus. 2016;37:154-160. https://doi.org/10.1080/08897077.2015.1132293

5. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65:1-49. https://doi.org/10.15585/mmwr.rr6501e1

6. Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1097-1102. https://doi.org/ 10.1213/01.ane.0000080159.83342.b5

7. Wilcox CE, Bogenschutz MP, Nakazawa M, et al. Concordance between self-report and urine drug screen data in adolescent opioid dependent clinical trial participants. Addict Behav. 2013;38:2568-2574. https://doi.org/10.1016/j.addbeh.2013.05.015

8. Zanis DA, McLellan AT, Randall M. Can you trust patient self-reports of drug use during treatment? Drug Alcohol Depend. 1994;35:127-132. https://doi.org/10.1016/0376-8716(94)90119-8

9. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. JAMA Intern Med. 2014;174:802-803. https://doi.org/10.1001/jamainternmed.2013.12809

10. Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002;18(4 suppl):S76-S82. https://doi.org/10.1097/00002508-200207001-00009

11. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156:569-576. https://doi.org/10.1097/01.j.pain.0000460357.01998.f1

12. Warner EA, Walker RM, Friedmann PD. Should informed consent be required for laboratory testing for drugs of abuse in medical settings? Am J Med. 2003;115:54-58. https://doi.org/10.1016/s0002-9343(03)00236-5

13. Kelly JF, Wakeman SE, Saitz R. Stop talking ‘dirty’: clinicians, language, and quality of care for the leading cause of preventable death in the United States. Am J Med. 2015;128:8-9. https://doi.org/10.1016/j.amjmed.2014.07.043

14. Jarvis M, Williams J, Hurford M, et al. Appropriate use of drug testing in clinical addiction medicine. J Addict Med. 2017;11:163-173. https://doi.org/10.1097/ADM.0000000000000323

15. Argoff CE, Alford DP, Fudin J, et al. Rational urine drug monitoring in patients receiving opioids for chronic pain: consensus recommendations. Pain Med. 2018;19:97-117. https://doi.org/10.1093/pm/pnx285

16 Ainscough TS, McNeill A, Strang J, et al. Contingency management interventions for non-prescribed drug use during treatment for opiate addiction: a systematic review and meta-analysis. Drug Alcohol Depend. 2017;178:318-339. https://doi.org/10.1016/j.drugalcdep.2017.05.028

17. Blum K, Han D, Femino J, et al. Systematic evaluation of “compliance” to prescribed treatment medications and “abstinence” from psychoactive drug abuse in chemical dependence programs: data from the comprehensive analysis of reported drugs. PLoS One. 2014;9:e104275. https://doi.org/10.1371/journal.pone.0104275

18. Miller SC, Fiellin DA, Rosenthal RN, et al. The ASAM Principles of Addiction Medicine. 6th ed. Wolters Kluwer; 2018.

19. Saitman A, Park H-D, Fitzgerald RL. False-positive interferences of common urine drug screen immunoassays: a review. J Anal Toxicol. 2014;38:387-396. https://doi.org/10.1093/jat/bku075

20. Smith MP, Bluth MH. Common interferences in drug testing. Clin Lab Med. 2016;36:663-671. https://doi.org/10.1016/j.cll.2016.07.006

21. George S, Braithwaite RA. An investigation into the extent of possible dilution of specimens received for urinary drugs of abuse screening. Addiction. 1995;90:967-970. https://doi.org/10.1046/j.1360-0443.1995.9079679.x

22. Beck O, Bohlin M, Bragd F, et al. Adulteration of urine drug testing—an exaggerated cause of concern. [Article in Swedish] Lakartidningen. 2000;97:703-706.

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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

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.

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

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