Urine Drug Testing, Treatment Compliance, and Managing Risk in Pain Management: A Q&A with Joshua Gunn, PhD

FEBRUARY 20, 2012
"We’re never going to replace one test with the other, but used together they can be very useful because blood picks up where urine leaves off."
What should clinicians keep in mind when it comes to patient selection for ongoing monitoring? Should testing be used with all patients who are prescribed a controlled substance, or only with high-risk patients?
This topic comes up at a lot of the national meetings. There is no one standard of care right now; there is no one guideline that must be followed when it comes to frequency of testing. But one of the trends that we’re seeing is this idea of risk stratification. I believe in risk stratification. I believe that patients who have been compliant since their initial visit and given the physician no reason to doubt them as a compliant patient may not be the best candidates to have four urine drug tests a year. They may only require one or two drug tests a year.

If, however, on the initial visit a patient gave the provider reason to be somewhat suspicious of their results, then I think the patient should be classified as low-risk, medium-risk, or high-risk. For some of the high-risk patients, it’s not uncommon to see them being tested three or four times a year. In today’s environment, prescribing a controlled substance is justification enough for an initial drug test. But, in my mind, as a toxicologist, I believe the frequency of testing should be based off of that initial drug screen, which is why many providers who are initiating urine drug testing are starting the process off with a urine baseline test on every patient that has been prescribed a controlled substance. By doing a baseline test, you get an overall picture of what’s going on in the practice, with data on every single patient prescribed a controlled substance. If a compliant result matches up with a compliant history for a certain patient, they may not have another drug test until six months later or the following year. Whereas a patient with a history of addiction or abuse, or with a family history, who also returns a concerning urine drug test may certainly go into the high-risk category and be drug tested the following quarter, the following visit, the following refill, or however it is determined in that specific practice.

Does regular testing create an atmosphere of mistrust between patients and their providers, or is that concern overhyped?
I have a lot of conversations with providers about that, especially with family physicians in rural areas of America. Many of these providers know their patients and their families better than anybody. They’ve often known them for a long time, and they’re a little unnerved by the idea of starting to drug test their patients out of the blue, because I think for many patients a urine test is associated with the idea that “you’re trying to catch me doing something I shouldn’t be or you suspect that I’m doing something I shouldn’t be.”

"Many of them are taking the following approach when explaining to patients why they are testing them. They say, “The state is requiring that I do this to keep my license. I need to do this to protect you. I need to do this to make sure that you don’t have anything in your system that’s going to interact with what I’m prescribing, and we need to make sure that you’re metabolizing and excreting these drugs accordingly."
As I talk to more and more providers about this, I find that many of them are taking the following approach when explaining to patients why they are testing them. They say, “The state is requiring that I do this to keep my license. I need to do this to protect you. I need to do this to make sure that you don’t have anything in your system that’s going to interact with what I’m prescribing, and we need to make sure that you’re metabolizing and excreting these drugs accordingly.” Regardless, many patients are going to be uneasy about a urine drug test and that may have the potential to generate some discomfort or tension between the provider and the patient. Providers need to get past that, because as more and more of them begin to do urine testing, they’re finding that some of the patients whom they would never have suspected of being involved in some of these behaviors in fact are, and have been for quite some time.

In the past, when providers were mainly concerned about patients using illicit drugs, there were clinical signs that providers were trained to recognize that may indicate drug abuse or drug dependency. Those still stand, but the problem we’re facing today is that providers may be dealing with patients who are not using these illicit drugs at all. They’re instead obtaining prescription medications and diverting them on the street for money. So how are providers going to identify that in a patient who has no clinical signs of abuse or addiction? We’re dealing with a whole other aspect of aberrant behaviors, and because of that I think we need to look beyond the trust issue and realize that testing protects not only the provider but also the patient.



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