Random Urine Drug Testing Research Articles

Random urine drug testing among patients receiving opioid therapy for cancer pain.

There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics. Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU. In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01). Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

Systematic urine drug testing for detecting and managing opioid misuse among chronic noncancer pain patients in primary care-The HARMS Program: A retrospective chart review of 77 patients.

The prevalence of opioid abuse has reached an epidemic level. National guidelines recommend safer opioid prescribing practices, including potentially monitoring patients with urine drug testing (UDT). There is limited research evidence sur-rounding the use of UDT in the context of chronic noncancer pain (CNCP). We evaluated the efficacy of systematic, randomized UDT to detect and manage opioid misuse among patients with CNCP in primary care. The Marathon Family Health Team (MFHT) designed and implemented a clinic-wide, randomized UDT program called the HARMS (High-yield Approach to Risk Mitigation and Safety) Program. This retrospective chart review includes 77 CNCP patients being pre-scribed opioids, who were initially stratified by their prescriber as "low-risk." Each month, 10 percent of patients were selected for a random UDT with double testing (immunoassay and liquid chromatography-mass spectrometry). The pri-mary outcome measure was UDT leading to a change in management plan. Of the 77 patients in the study, 55 (71 per-cent) completed at least one UDT during the 12-month study period. Overall, 22 patients had aberrant results. UDT led directly to changes in management in 15 of those patients. Four of those 15 patients were escalated to an addictions program, two were tapered from opioids with informed discussion, and nine were escalated to the high-risk monitoring stream. The results of this study show that in low-risk CNCP patients prescribed opioids, applying systematic UDT in a primary care setting is effective for detecting high risk behaviors and addiction, and altering management. Further re-search is needed with larger numbers using a prospective study design.

Random versus targeted urine drug testing among cancer patients receiving opioid therapy at a supportive care clinic.

221 Background: Although urine drug testing (UDT) is an effective risk monitoring tool for patients on chronic opioid therapy, there is currently no evidence to guide physicians in identifying who should have UDT, or when and how often it should be ordered. The main objective of our study was to describe the characteristics of patients who underwent random UDT and a similar cohort who underwent targeted UDT. Methods: Demographic and clinical information of 212 patients who underwent random UDT was retrospectively reviewed and compared with 88 patients who underwent targeted UDT. Targeted UDT was ordered based on the physician’s estimation of patient risk for nonmedical opioid use. All patients were eligible for random UDT regardless of their risk potential for nonmedical opioid use. Results: 212/231 (92%) eligible patients underwent random UDT. Of these 59 (28%) had abnormal results. Among 64 abnormalities detected, 14 (20%) were prescribed opioids that were absent from the urine, 19 (30%) were unprescribed opioids that were present, and 32 (50%) were illicit drugs (91% marijuana). 38/88(43%) of targeted patients had abnormal results. Among 49 abnormalities detected, 13 (27%) were prescribed opioids that were absent from the urine, 15 (31%) were unprescribed opioids that were absent, and 21 (43%) were illicit drugs (71% marijuana). UDT abnormalities were significantly higher in the targeted group than the random group (43.2% vs. 27.8%, p=0.01). There were no significant differences in demographic and clinical characteristics between random and targeted patients with abnormal UDT findings. UDT abnormality was independently associated with age (OR= 0.97 per year, 95% CI: 0.95-0.99, p=0.012), female gender (OR=0.47, 95% CI: 0.28-0.81, p=0.006), anxiety (OR=1.11per point, 95% CI: 1.01-1.22, p=0.039), and appetite (OR= 1.14 per point, 95% CI: 1.04-1.26, p=0.006). Conclusions: More than 1 in 4 cancer patients who underwent random UDT had abnormal results. UDT abnormality in randomly selected patients were no different from targeted patients. Further studies are needed to guide clinical practice regarding standardization of UDT ordering among patients with cancer.

Reducing the Incidence of Substance Use Disorders in Anesthesiology Residents: 13 Years of Comprehensive Urine Drug Screening.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The incidence of substance use disorders in the United States among residents in anesthesiology is between 1% and 2%. A recent study reported that the incidence of substance use disorders in U.S. anesthesiology residents has been increasing. There are no reports of effective methods to prevent substance use disorder in residents. A comprehensive drug testing program including a random component may reduce the incidence of substance use disorders. The authors initiated a comprehensive urine drug screening program of residents, fellows, faculty physicians, and certified nurse anesthetists. The authors performed 3,190 tests over 13 yr. The authors determined the incidence of substance use disorders among residents in our large anesthesiology residency program during the decade before (January 1, 1994, to December 31, 2003) and for the 13 yr after (January 1, 2004 to December 31, 2016) instituting a random urine drug testing program. A total of 628 residents trained in the program over these 23 yr; they contributed a total of 1,721 resident years for analysis. Fewer faculty and certified nurse anesthetists were studied, so we do not include them in our analysis. The incidence of substance use disorders among trainees in our department during the 10 yr before initiation of urine drug screening was four incidents in 719 resident years or 0.0056 incidents per resident-year. In the 13 yr after the introduction of urine drug screening, there have been zero incidents in 1,002 resident years in our residency program (P = 0.0305). This single-center, comprehensive program including preplacement and random drug testing was associated with a reduction of the incidence of substance use disorders among our residents in anesthesiology. There were no instances of substance use disorders in our residents over the recent 13 yr. A large, multicenter trial of a more diverse sample of academic, government, and community institutions is needed to determine if such a program can predictably reduce the incidence of substance use disorders in a larger group of anesthesiology residents.

Drug Detection in Urine for Evaluating Exposure-No Limits!

The major goals of exposure testing in the chronic pain or addiction management setting are to verify that a patient has recently taken the drug(s) prescribed to him or her, and to detect use of nonprescribed drugs. Random urine drug testing, used in combination with other tools for evaluating patient behavior, is thought to reduce the likelihood of drug misuse and thereby promote patient safety and efficacy. Urine drug tests are recommended by the 2016 Guideline for Prescribing Opioids for Chronic Pain that was published by the Centers for Disease Control and Prevention (1), as well as many professional associations, including the American Pain Society and the American Association of Pain Management. That said, no test is perfect—no single drug test can detect all drugs—and detection of drugs does not equate to adherence with therapy. Some laboratories have applied forensic drug-testing principles and practices from the federal workplace drug-testing program, managed by the Substance Abuse and Mental Health Services Administration (SAMHSA)3, to urine drug testing performed in a clinical setting. This makes sense because the SAMHSA program mandates content of drug tests and cutoffs, i.e., the concentration thresholds used to differentiate positive from negative results. However, experience has demonstrated that the drugs of interest to chronic pain or addiction management, …

Substance abuse: a national survey of Canadian residency program directors and site chiefs at university-affiliated anesthesia departments.

The abuse of substances available to anesthesiologists in their workspace is a potentially lethal occupational hazard. Our primary objective was to define the prevalence of substance abuse cases among Canadian anesthesiologists at university-affiliated hospitals. Our secondary aim was to describe the current management of confirmed cases, rehabilitation procedures being offered, and preventative strategies being employed. We conducted a cross-sectional electronic survey of all Canadian anesthesia residency program directors and site chiefs at university-affiliated hospitals. Data analysis was performed using descriptive statistics. The survey response rate was 54% (53/98). Substance abuse was reported as 1.6% for residents and 0.3% for clinical fellows over a ten-year period ending in June 2014. Fentanyl was abused in nine of 24 reported cases. At present, one of 22 respondents (4.5%) reported a formal education program on substance abuse for faculty members, and 72% described mandatory education for residents. The majority of participants did not perceive substance abuse as a growing problem. Seventy-one percent of respondents indicated that methods for controlled-drug handling had changed in the previous ten years; however, 66% did not think that the incidence of controlled substance abuse could be decreased further by more stringent measures. Only 21% of respondents supported the introduction of random urine drug testing. The prevalence of substance abuse among Canadian anesthesiologists and the substances abused appear comparable with data from the United States, with residents being the group most often affected. Early recognition and treatment of chemically dependent anesthesiologists remain imperfect.

Prescription Patterns of Pain Medicine Physicians

Our study surveyed physician members of 3 American pain societies to determine prescription patterns and whether these practices reflect current expert opinion. We sent 3 mailings to 2938 physicians from January 2010 to January 2011. The questionnaire contained 49 questions on topics related to opioids, antidepressants, anticonvulsants, and preferences for the different pain syndromes. A total of 474 physicians responded, representing a 16% return. Seventy-two percent ask patients to sign an opioid agreement, 59% order random urine drug testing, 13% wait until the dose of methadone is between 100 and 150mg before converting the drug to another opioid, and 85% do not think there is a maximum dose of opioids with respect to driving. Most responders prescribe codeine to Caucasians and Asians. While 42% stated that the maximum daily dose of acetaminophen is 3000mg, 75% would decrease the dose in patients who are moderate or heavy drinkers. Fifty-four percent do not order an ECG at all when prescribing tricyclic antidepressants. The responses pertaining to opioid agreements, urine drug testing, acetaminophen, and treatment for neuropathic pain are reassuring in that they prevent misuse and abuse of opioids, prevent acetaminophen-induced hepatotoxicity, and reflect evidence-based treatments. However, we identified gaps in knowledge, including the prescription of codeine in certain populations and the use of electrocardiogram in patients on antidepressants. Further education of physicians who treat chronic pain pharmacologically is warranted.

Comparison of Random and Postaccident Urine Drug Tests in Southern Indiana Coal Miners

This study examines the relationship between the use of 9 classes of substances (amphetamines, barbiturates, benzodiazepines, cocaine, marijuana, methadone, opioids, phencyclidine, and propoxyphene) and coal-mining accidents. The control sample (n = 215) made up of miners that presented for random urine drug testing. The study sample (n = 100) consists of miners that presented for postaccident urine drug testing. Nonparametric Mann-Whitney U tests of creatinine normalized urine drug levels were conducted to compare the medians of the groups. The mean drug concentrations were higher in the postaccident group for each drug tested except marijuana. Two-tailed testing demonstrated statistically significant differences for marijuana (P = 0.000), cocaine (P = 0.008), and opiates (P = 0.037). The study demonstrates statistically significant higher cocaine and opioid concentrations and lower marijuana concentrations in postaccident urine drug tests of coal miners when compared with random tests.

Improving use of narcotics for nonmalignant chronic pain: A lesson from Community Care of North Carolina

To describe the development, implementation, and effects of collaborative effort to reduce diversion of prescription drugs in Caldwell County, NC. Development and implementation of practice guideline, statewide opioid registry, and survey of all primary care providers. Rural Caldwell County, NC, has a population of 83,029, of which 89 percent are non-Hispanic White; 2009 median household income of $35,489. All primary care clinicians in the county (N = 35). A task force developed and implemented a practice guideline that encouraged the following: 1) signing of pain contracts; 2) requiring patients to undergo random urine drug testing; and 3) requiring random pill counts. North Carolina implemented a statewide registry in 2007 that contained information on virtually all opioid prescriptions filled by pharmacies. Opioid pill confiscations by the Caldwell County Narcotics Division 24 months prior to implementation of the guidelines, the first 12 months during guideline implementation, and 12 months after the guideline was fully implemented. From 2005 to 2007, opioid pill confiscations decreased by 300 percent. Of the 35 physicians who were sent surveys, 27 responded (77 percent response rate). Ninety percent of respondents who prescribe opioids use the chronic pain guidelines. Sixty percent report an improvement in the overall management of patients with chronic pain; 65 percent reported having more confidence in treating patients with chronic pain; and 60 percent reported using the opioid registry. This county wide medical initiative appears to have resulted in a significant improvement in the abuse and diversion of medically derived opioids.

Improving use of narcotics for nonmalignant chronic pain: A lesson from Community Care of North Carolina

Objective: To describe the development, implementation, and effects of collaborative effort to reduce diversion of prescription drugs in Caldwell County, NC. Design: Development and implementation of practice guideline, statewide opioid registry, and survey of all primary care providers. Setting: Rural Caldwell County, NC, has a population of 83,029, of which 89 percent are non-Hispanic White; 2009 median household income of $35,489. Patients, participants: All primary care clinicians in the county (N = 35). Interventions: A taskforce developed and implemented a practice guideline that encouraged the following: 1) signing of pain contracts; 2) requiring patients to undergo random urine drug testing; and 3) requiring random pill counts. North Carolina implemented a statewide registry in 2007 that contained information on virtually all opioid prescriptions filled by pharmacies. Main outcome measure(s): Opioid pill confiscations by the Caldwell County Narcotics Division 24 months prior to implementation of the guidelines, the first 12 months during guideline implementation, and 12 months after the guideline was fully implemented. Results: From 2005 to 2007, opioid pill confiscations decreased by 300 percent. Of the 35 physicians who were sent surveys, 27 responded (77 percent response rate). Ninety percent of respondents who prescribe opioids use the chronic pain guidelines. Sixty percent report an improvement in the overall management of patients with chronic pain; 65 percent reported having more confidence in treating patients with chronic pain; and 60 percent reported using the opioid registry. Conclusions: This countywide medical initiative appears to have resulted in a significant improvement in the abuse and diversion of medically derived opioids. Keywords: law enforcement, collaboration, practice guideline, primary care DOI:10.5055/jom.2012.0136

Random Urine Drug Testing

Random Urine Drug Testing

Random Urine Drug Testing

To the Editor: Although the desired outcome for Fitzsimons et al.1 was to “reduce the incidence of addiction,” their surrogate marker of success was a reduction in the number of positive urine tests. Care must be taken not to assume that the cost-benefit of random urine testing in a population in which 100% abuse (drug treatment monitoring program) translates to a population in which 1% are substance abusers (anesthesia residency) and justify this assumption with preliminary data.2 The validity of their surrogate marker depends on the compliance of the tested population and the integrity of the urine sample. Both are in question. Only 150 random samples were collected over 4 yr, less than half required by protocol. Their steps to protect the privacy, dignity, and work ethic of the 99% of residents unlikely to be substance abusers created easy opportunities for the remaining 1% to either opt out of testing or provide an invalid specimen. The 36-h response window allows the individual substance abuser time to acquire a urine sample not his/her own or add a urine adulterant or to water load. Write in “pass drug test” on Google to secure overnight delivery of a clean urine specimen or the latest generation of adulterants.3,4 Devices may be purchased to subvert even witnessed collection (“Whizzinator” and “Butt Wedge”).3 In 2004, the Substance Abuse and Mental Health Services Administration published adulterant testing guidelines.5 The Department of Transportation now makes specimen validity testing mandatory.6 Hair sampling, frequently positive in known substance abusers with negative urine tests, bypasses privacy concerns, but is more expensive than urine testing.7 Saliva testing is undergoing validation.8 Successful monitoring programs combine both random testing and behavioral monitoring.9 But approximately 20% of individuals with known drug dependence escape detection based on behavioral monitoring alone.10 Experienced opioid users may self-inject drugs at work with a sufficient dose to prevent withdrawal symptoms but not impair performance and thereby escape detection. The average age of onset for substance abuse is 20 yr.11 Thus, residents whose addiction becomes manifest during residency have gone undetected in medical school and during residency recruitment. Margaret F. Brock, MD Raymond C. Roy, MD, PhD Department of Anesthesiology Wake Forest University School of Medicine Medical Center Boulevard Winston-Salem, North Carolina [email protected]

The Opioid Renewal Clinic: A Primary Care, Managed Approach to Opioid Therapy in Chronic Pain Patients at Risk for Substance Abuse

To measure the impact of a structured opioid renewal program for chronic pain run by a nurse practitioner (NP) and clinical pharmacist in a primary care setting. Patients with chronic noncancer pain managed with opioid therapy in a primary care clinic staffed by 19 providers serving 50,000 patients at an urban academic Veterans hospital. Naturalistic prospective outcome study. Based on published opioid prescribing guidelines and focus groups with primary care providers (PCPs), a structured program, the Opioid Renewal Clinic (ORC), was designed to support PCPs managing patients with chronic noncancer pain requiring opioids. After training in the use of opioid treatment agreements (OTAs) and random urine drug testing (UDT), PCPs worked with a pharmacist-run prescription management clinic supported by an onsite pain NP who was backed by a multi-specialty Pain Team. After 2 years, the program was evaluated for its impact on PCP practice and satisfaction, patient adherence, and pharmacy cost. A total of 335 patients were referred to the ORC. Of the 171 (51%) with documented aberrant behaviors, 77 (45%) adhered to the OTA and resolved their aberrant behaviors, 65 (38%) self-discharged, 22 (13%) were referred for addiction treatment, and seven (4%) with consistently negative UDT were weaned from opioids. The 164 (49%) who were referred for complexity including history of substance abuse or need for opioid rotation or titration, with no documented aberrant drug-related behaviors, continued to adhere to the OTA. Use of UDT and OTAs by PCPs increased. Significant pharmacy cost savings were demonstrated. An NP/clinical pharmacist-run clinic, supported by a multi-specialty team, can successfully support a primary care practice in managing opioids in complex chronic pain patients.

Coping with Chronic Pain in Gastroenterology Patients

Coping with Chronic Pain in Gastroenterology Patients