Pain Physician 2012; 15:ES119-ES133 • ISSN 2150-1149 Current Opinion Urine Drug Testing: Current Recommendations and Best Practices Graves T. Owen, MD1, Allen W. Burton, MD2, Cristy M. Schade, MD, PhD3, and Steve Passik, PhD4 From: 1Texas Pain Rehabilitation Institute, 2Houston Pain Associates, Background: The precise role of urine drug testing (UDT) in the practice of pain Houston TX; 3RSD and Back Pain Center medicine is currently being defined. Confusion exists as to best practices, and even to 4 of Dallas, TX; Vanderbilt University what constitutes standard of care. A member survey by our state pain society revealed Medical Center, Nashville, TN. variability in practice and a lack of consensus. Dr. Owen is with the Texas Pain Rehabilitation Institute Objective: The authors sought to further clarify the importance of routine UDT as an Dr. Burton is with Houston Pain important part of an overall treatment plan that includes chronic opioid prescribing. Associates, Houston, TX. Dr. Schade is with RSD and Back Pain Further, we wish to clarify best practices based on consensus and data where available. Center of Dallas, TX. Dr. Passik is a Professor of Psychiatry Methods: A 20-item membership survey was sent to Texas Pain Society members. and Anesthesiology at Vanderbilt A group of chronic pain experts from the Texas Pain Society undertook an effort to University Medical Center, Nashville, TN. review the best practices in the literature. The rationale for current UDT practices is clarified, with risk management strategies outlined, and recommendations for UDT Address correspondence: outlined in detail. A detailed insight into the limitations of point-of-care (enzyme-linked Allen W. Burton, MD immunosorbent assay, test cups, test strips) versus the more sensitive and specific Houston Pain Associate laboratory methods is provided. 7700 Main Street #400 Houston, TX E-mail: [email protected] Limitations: Our membership survey was of a limited sample size in one geographic area in the United States and may not represent national patterns. Finally, there is Disclaimer: There was no external limited data as to the efficacy of UDT practices in improving compliance and curtailing funding in the preparation of this manuscript. overall medication misuse. Conflict of interest: None. Conclusions: UDT must be done routinely as part of an overall best practice program Manuscript received: 07/07/2011 in order to prescribe chronic opioid therapy. This program may include risk stratification; Revised manuscript received: 08/28/2011 baseline and periodic UDT; behavioral monitoring; and prescription monitoring programs Accepted for publication: 08/31/2011 as the best available tools to monitor chronic opioid compliance. Free full manuscript: Key words: Urine drug screening, urine toxicology screening, urine drug testing, www.painphysicianjournal.com chronic pain, addiction, forensic testing Pain Physician 2012; 15:ES119-ES133 exas Pain Society (TPS) members have been that UDT is well accepted, but its application is widely querying the TPS Board of Directors (of which variable (Appendix 1). The survey was emailed twice to T3 of the authors are members) with increasing 280 members; 102 replied, a 36% response rate. Thus, frequency about urine drug testing (UDT) standard of this manuscript was born out of membership demand care questions. Responding to membership concerns, and the TPS’s purpose of promoting and maintaining the TPS performed a membership survey which revealed the highest standards of professional practice through www.painphysicianjournal.com Pain Physician: Opioid Special Issue July 2012; 15:ES119-ES133 education and research. The authors felt that there United States, compared with 12.6% from heroin (1,4). would be interest in the general pain community beyond Clark and colleagues (2) reported a 3-fold increase in Texas to view the topic of urine drug screening (UDS) opioid abuse in recent years. Two-thirds of abused opi- through the prism of one state society’s reaction to this oids originate from a valid prescription; one-fifth are developing issue. Urine drug screening (UDS) typically obtained from more than one physician. Among pa- refers to the first step of a two-step process involving tients receiving treatment for opioid dependency, 50- screening (typically immunoassay) and confirmation 60% obtained the drugs from their physicians (3). One (chromatographic and mass spectrometric methods). study estimated that the minimum economic burden For the purposes of testing in general, the abbreviation for prescription opioid abuse in 2005 was $9.5 billion “UDT” (urine drug testing) may be preferable. (4). The United States contains 5% of the world’s popu- A perfect storm has developed involving prescrip- lation but consumes 99% of the world’s hydrocodone. tion opioid medications. Throughout the past few Similar disproportionate consumption by the United decades, awareness of untreated and unrecognized States occurs with other opioids as well (5) (Table 1). pain has increased, along with subsequent educa- Between 1992 and 2003, although the U.S. popu- tional efforts enlisting doctors to assess and treat pain lation grew only 14%, the number of people who ad- more aggressively. The term opioidphobia was coined mitted to prescription analgesic abuse increased 94%. to describe doctors’ reluctance to prescribe opioid About this same time (1992 to 2002), first-time abuses medications. of prescription opioids among 12- to 17-year-olds in- Efforts to treat pain more aggressively started in creased 542% (6). the 1990s and reached full stride around 2000, when The prevalence of addiction in the general popula- even the U.S. Congress proclaimed the years 2000- tion is estimated to be 3-16% (7). Although addiction in 2010 the Decade of Pain Control and Research. Both the pain management setting has been considered un- the American Pain Society and the American Academy common, more recent studies examining UDT suggest of Pain Medicine wrote formal position statements that the rate of problematic drug-related behaviors in endorsing the prescribing and use of chronic opioid the chronic pain clinic setting is far higher (8,9,12,18, therapy (COT) for pain. As a result of these efforts, the 35,37-40). Many patients with moderate or severe prescribing of opioids increased substantially. chronic pain who believe they need ongoing COT are The increased availability of opioids appears to psychologically distressed, with a reported 70% preva- have led to unanticipated problems, including an ex- lence of psychosocial comorbidities in patients with plosion in nontherapeutic opioid use. In fact, a nation- chronic pain (9). Deyo and Edlund (9,41) found that al epidemic in the nontherapeutic use of opioids has COT use is increasing more rapidly in patients with emerged in the United States. Deaths from the misuse mental health and/or substance abuse disorders than of prescription opioids currently exceed deaths from in patients without these disorders. This is particularly heroin overdose. Deaths from prescription opioids worrisome because patients with mental health and/or account for 18.9% of all drug-related deaths in the substance abuse disorders are at greatest risk of using controlled substances nontherapeutically. Pain is a subjective process, and clinicians must rely Table 1. Percentage of U.S. consumption of world’s opioid on subjective reports from patients to make treatment production (5)(note: hydrocodone is not available in some decisions. Addicted individuals, as part of their disease countries). state, will not provide truthful self-reports if the report could result in their not receiving their drug of choice. Opioid Percentage Significant data have shown that self-reported drug Hydrocodone 99 use in the chronic pain population is often unreliable Oxycodone 80 (11). Therefore, clinicians must analyze a combination of subjective input and objective observations to assess Methadone 58 their patients. Objective observations include pill counts Hydromorphone 54 (admittedly difficult to do), prescription monitoring Fentanyl 49 programs, and monitoring for aberrant behaviors. Aberrant behaviors may include early refill requests Meperidine 43 (self-escalation), reports of “lost or stolen” medica- ES120 www.painphysicianjournal.com Urine Drug Testing: Current Recommendations and Best Practices tions, treatment noncompliance, and UDT that does not psychometric screening tools, provides a valuable risk- include the prescribed drug and may include illicit or assessment basis with which the clinician can assess the nonprescribed controlled substances. Monitoring of ab- patient’s candidacy for COT and comply with the TMB errant behavior alone is inadequate and frequently re- rule. sults in underestimated aberrant drug-taking behavior The following risk factors associated with aberrant (11,12,10). A combination of monitoring for aberrant drug use have been identified by numerous studies: behavior and use of UDT has been recommended as the personal or family history of alcoholism or substance best available monitoring strategy (11,12). abuse (past or present), nicotine dependency, age < 45 The differential diagnosis for aberrant drug-taking years, depression, impulse control problems (attention behaviors includes addiction, pseudoaddiction, chemi- deficit disorder, bipolar disease, obsessive-compulsive cal coping, organic mental syndrome, personality dis- disorder, schizophrenia, personality disorders), hyper- order, self-medicating depression, anxiety,