Urine drug screens (UDS) in primary care

Ordering periodic urine drug screens (UDS) on patients being treated with opiates for chronic pain has become so common it is now the de facto standard of care. That doesn’t mean it benefits patients. 

Opiates like oxycodone, oxycontin, methadone, morphine, hydrocodone, and hydromorphone are potent and effective pain medications. They also are highly addictive, abusable, have significant side effects, have a high ‘street value’ and are associated with an unacceptable number of accidental deaths by overdose.  They should be used for chronic pain only after other safer approaches have been tried and have failed. Even then, they require a frank and full discussion with the patient about the potential risks.  Which brings me to the issue of the UDS.

Most institutions and clinicians require a ‘narcotic contract’ before they will prescribe opiates for chronic pain. This contract is often confused with (or used as) informed consent. It always lists requirements for the patient:

  • Only fill the prescription at one pharmacy, specified in the contract.
  • Receive no narcotics from any other medical source without first getting permission from the primary prescriber.
  • Never ask for early refills, even if the medication is lost or stolen. (Requests for early refills are considered de facto evidence of overuse.)
  • Never ask for refills on holidays, weekends or after hours.
  • No dose changes except at a face-to-face visit.
  • Use of any illegal substances constitutes violation of the contract.

And, the subject of my comments today:

  • Upon request by the prescribing clinician, the patient is obligated to bring in their remaining pills for a ‘pill count’ or give a sample for a UDS. (Usually required the same day as the phone call requesting it.)

(Note: a formal agreement with the patient about opiate prescribing is a good practice. It can foster clinical collaboration. Both the treatment of chronic severe pain and the use of chronic opiates are difficult for both the patient and clinician. The benefits of an explicit discussion of the goals, principles, limits and processes for treatment should be obvious. Ironically, all the opiate ‘contracts’ I have seen are one sided. They define in rather unfriendly language the obligations of the patient and the consequences of violations, but they never list the obligations of the prescribing clinician or the goals or parameters of care.)

Of course, the UDS is not a $10 office test.  The charge is commonly in the $400-$600 dollar range (although with some diligence, one may find a lab that charges as little as $250 for a screen), there may be a significant co-pay, it may only be covered after the deductible is met, some insurances do not cover it, and patients with no insurance - not rare in the chronic pain population - are responsible for the entire amount. I have had patients who were expected by their pain clinician to pay out of pocket for a UDS 2-3 times a year.

There are two reasons to do UDS testing in patients getting long term opiates for chronic pain. The first two are legitimate, but the third is hypocritical and self-serving.

The first reason is public safety. I see value in the prevention of diversion. A very small minority of patients are either faking their pain, or exaggerating it, in order to acquire opiates to sell. If a patient cannot produce the expected number of pills, or gives a urine sample that does not have opiates in it, one can assume they are not taking the medication and therefore do not need it.  Of course, the target population of abusers is well aware of this, so there is a thriving market for ‘pill count pills’ and ‘clean’ urine.  This requirement is more likely to inconvenience and offend legitimate users than it is to catch criminals.   (“Hello Mr. Greene. This is Dr. Elias’ nurse. Dr. Elias wants you to take unannounced time off work today so you can come to the office and give us a urine sample.”) 

The second, and most commonly cited, reason for doing a UDS is the one I do not see as valid: to make sure the patient is not taking other drugs with abuse potential, such as marijuana, cocaine, amphetamines, or benzodiazepines. This boils down to a paternalistic decision to ‘protect’ the patient from ‘making bad decisions’ by behaving in a way the clinician thinks is inappropriate. “If they are taking ativan, smoking marijuana, or use cocaine occasionally, then I shouldn’t prescribe an opiate.”  

WTF? (I apologize for the language, but no other phrase really fits.)

If the patient has pain that requires an opiate, their use of marijuana (or benzos, amphetamines, alcohol, tobacco, or coffee) should not keep me from prescribing the opiate they need.  None of the clinicians (or hospital risk managers or medical administrators) who advocate for UDS use in chronic pain patients treated with opiates would suggest any of the following, ALL of which make at least as much medical sense, if the motivation is to prevent patient harm:

  • Test periodic urinary cotinine levels in patients with COPD, asthma, coronary artery disease or peripheral vascular disease, and refuse to prescribe medications for these conditions if they have (+) cotinine testing indicating that they use cigarettes.
  • Test for caffeine or alcohol in patients getting zolpidem or trazadone for sleep, and refuse to prescribe their sleep medication if they are doing things that are known to disrupt sleep. (Like watch TV or use a computer in the 2 hours before bedtime.)
  • Refuse to prescribe allergy medication or asthma MDIs in patients who have pets at home despite testing that shows that they are allergic.
  • Require that patients on anticoagulants (warfarin/coumadin) sign a contract saying they will only get medications from their primary provider and one pharmacy, so as not to risk getting medications that increase their risk of bleeding or stroke.
  • Do a UDS (including for alcohol) on patients getting medications for OCD, depression, anxiety, PTSD, schizophrenia, bipolar illness and refuse to prescribe their therapeutic medications if they are using anything the clinician has not prescribed.

The urine drug screen is a test ordered by the clinician primarily for the legal protection of the clinician and their institution. It has little or no benefit for the patient.  If it is done to prevent diversion (which, as I said, is legitimate but does not require a full panel and is only rarely necessary) I think it can be justified. If it is done to protect the patient from himself, then I think it has no justification at all. In either case, since it is never done to benefit the patient, the patient should never be asked to pay. 

 




 

 

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