The utility of universal urinary drug screening in chronic pain management

Abstract

Background: A recent systematic review found few studies that assessed the value of urinary drug screening (UDS) in the management of chronic pain. The Pain Management Unit in Halifax, Nova Scotia, has recently implemented tandem mass spectrometry (TMS) UDS for all new patients. Aims: To study the prevalence of unexpected TMS UDS results at a hospital-based chronic pain center, to assess which drugs are most likely to contribute to an unexpected result and to assess the clinical utilization of unexpected results by pain physicians. Methods: From June 2014 to June 2016, a total of 664 patients with chronic non-cancer pain (CNCP) were seen for initial consult. Charts were reviewed and used to create a database containing sex, age, UDS result, physician, and medication/illicit drug history. For all unexpected UDS results, an interview was conducted with the treating physician to determine its clinical implications. Results: For the general pain specialists, the overall percentage of patients with an unexpected UDS result was 16.67%. Excluding codeine, at most 4.47% of patients tested unexpectedly positive for a strong opioid. Although eight out of nine physicians found UDS helpful in general, only 29.58% of unexpected results were helpful in the management of their patients and directly influenced their care. Conclusions: The prevalence of an unexpected UDS result in patients with CNCP is significant. Most physicians agree that UDS is helpful but in only a limited number of cases did the unexpected result provide helpful information that significantly influenced patient care.

Opioid Knowledge and Prescribing Habits at a Large Tertiary Care Academic Center

“…In 2016, the CDC released its Opioid Prescribing Guidelines and recommended the use of UDT upon opioid therapy initiation and annually thereafter to assess prescription and illicit drug use [5]. Numerous studies have shown that consistent UDT implementation has moderate efficacy in improving opioid adherence [20] and prescription safety [21,22], though consistent methodology between studies is lacking. Regardless, UDT provides a means of early opioid aberrancy detection that could influence treatment modifications and result in better outcomes.…”

<p>Opioid moderatism and the imperative of rapprochement in pain medicine</p>

“…Reckless overprescription is clearly inconsistent with aggressive risk mitigation, and is perhaps its antithesis. Although no single risk mitigation strategy is a panacea for opioid overuse, abuse, and diversion, practices such as medication agreements,71,72 consistent use of PDMPs,73–75 and urine drug toxicology (UDT)76–78 all have at least moderate evidence-bases for increasing prescription safety. However, the lack of use of these tools in many clinical settings in which pain is treated is disturbing.…”

“…The testing is performed in-house during the patient’s appointment, and the clinician has the results before seeing the patient. Although some have contended that certain physicians engage in urine drug overtesting based on profit motivation,78 the facility charges for only what is considered medically necessary by the insurance carrier. This is done in the purest spirit of opioid risk mitigation, the purpose of which is to protect individual patients as well as society, generally.…”

<p>Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety</p>

“…The use of “universal precautions” in opioid prescribing has been recommended since 2005,1 with urine drug toxicology (UDT) considered a crucial aspect of cautious risk mitigation. Although not necessarily a panacea, UDT has been demonstrated through a number of studies and reviews2–5 to have at least moderate efficacy for increasing prescription safety. The 2016 Centers for Disease Control and Prevention (CDC) Opioid Prescribing Guideline6 recommends UDT not only at the initiation of treatment with opioids, but periodically during the course of treatment as a means of increasing patient safety.…”