UDTs Common Tool
Urine drug tests (UDTs) are a common tool for a health care practitioner to use in order to guide and direct opioid prescribing. While there are no absolute requirements to do one before or during the prescribing of narcotics, many organizations recommend doing them as part of a comprehensive guidance for pain management. In fact, the CDC is advocating this test to be a part of care for individuals who would be considered to receive opioids chronically (over 90 days) at a frequency of at least once a year.1
While testing is important to aid care, excessive testing has occurred in many places. Millenium recently paid $256 million dollars to resolve allegations of unnecessary drug and genetic testing and illegal remunerations to physicians to the government.2 Labs and medical groups are being increasingly scrutinized and audited.3 Physician practices are being scrutinized for excessive testing and raising the ire of many patients required to get drug testings.4 Some physicians and physician groups are capturing millions of dollars by their excessive and unnecessary drug testing.
Inexpensive Qualitative Testing
When ordering UDTs, most practitioners will start with an inexpensive qualitative test showing whether a person has been using any illicit and some licit chemicals. The threshold for detection of a drug is usually set quite low but it is not zero and therefore it is possible for someone to have a drug in their system in a small enough quantity to not be detected by a qualitative test. To know the exact amount of a drug in a person’s system, a more expensive quantitative testing can be performed.
This initial testing can serve as an indicator on whether someone is candid about their life. If someone states they do not use any illicit substances and one is clearly revealed in the testing results, one can safely conclude that the patient has been disingenuous.
A question one has to consider is if a person does not show the presence of a drug by a qualitative test should extra money be spent to get a quantitative confirmation? No pain organization has answered this question with definitive guidelines leaving this open to interpretations that span the gamut of satisfaction with the qualitative results (most clinicians) to testing every possible drug in a panel quantitatively (few clinicians).
In addition to a general screen, one can test for specific medications a patient has been reportedly taking. There is again an inexpensive qualitative testing that shows the presence or absence of a chemical and then there is a more expensive quantitative testing that shows the exact concentration of the medication in question. This qualitative testing either supports or refutes the reports of a patient.
A significant part of guiding opioid prescribing is a risk assessment. This can occur by various means and tools are available to make it easy.5 By this means, a prescriber assesses a patient to be at low, moderate or high risk of substance abuse. “Patients who are typically at a lower risk for misusing opioids include those who are older, generally compliant, have a record of rarely misusing any medication, show stable mood, are thoughtful and responsible, and generally have an easy-going personality. Risk factors for opioid misuse include (1) family or personal history of substance abuse, (2) young age, (3) history of criminal activity and/or legal problems (e.g., charged driving under the influence, DUI), (4) frequent contact with high-risk individuals or environments, (5) history of previous problems with employers, family, and friends, (6) history of risk-taking/thrill-seeking behavior, (7) smoking cigarettes, (8) history of severe depression or anxiety, (9) multiple psychosocial stressors, and (10) previous drug and/or alcohol rehabilitation “6
Knowing the level of risk should guide the amount of UDTs and boundaries for compliance that one should expect in opioid therapy. While no pain organization has outlined the exact number of UDTs one should do in every situation, leaders in the pain management community, Dr. Webster 7and Dr. Manchikanti 8opined that low risk patients only need to be tested once a year.
Testing costs money. Standard qualitative testing can cost $500 while extensive quantitative testing can cost up to $2000. Testing is an essential part of medical care in guiding decision making. When repetitive and unnecessary testing is performed money is needlessly spent. The following case scenarios help to illustrate this point.
Patient X is a middle aged male who has failed surgical interventions and other reasonable means to manage his pain. His health care provider has figured out through trial and error that oxycontin is an effective means to control his pain. Patient X is a person who is considered at low risk for substance abuse. UDTs are ordered before initiating care and subsequently at every visit to guide care. The visits and UDTs are planned monthly. There is no discussion in the patient’s medical records on why repeated testing is planned or how the results will guide subsequent care. The health care practitioner influences patient X that he is getting great care by this repeated testing to evaluate him. Patient X is strained because he is dependent on oxycontin for pain relief and has to pay several hundred dollars a month as a copay for his UDTs; his insurance only pays for a portion of the cost.
The care provided by this practitioner is repetitive, costly and not indicated. A patient considered at low risk generally only requires one UDT per year. Medical tests should be guided by questions that will be answered by testing. Repeatedly asking the same question and receiving the same answer is unnecessary when you have already assessed their risks of problems with opioids at the onset of therapy.
All patients coming to a center are required to get a qualitative and quantitative UDT before they receive their opioid prescription. Their standard policy is followed regardless of their risk for substance abuse and occurs every month. Lack of submitting to the testing results in a discharge from the practice and cessation of opioid therapy. These patients were lead to believe in the necessity of the testing while no education about the process of testing and interpretation of the results is conveyed by the practitioners to the patients.
In this scenario, required testing on everyone is excessive and not indicated. In the general population, approximately 1/2 of individuals are at moderate to high risk for substance abuse 9and may require frequent testing; the frequency of testing in this group is based on judgment but should be reasonable. One half of the patients in this group (low risk patients) are being excessively tested. The patients in the moderate to high risk category are being excessively tested when they get quantitative testing on all qualitative results in addition to their getting tested and not evaluated by the health care practitioner.
Costs to Patients, Insurance Companies, and the Government
Excessive and unnecessary UDTs cost patients, insurance companies and the government hundreds of millions of dollars per year .10There are no guidelines from any medical society that justifies this form of testing. When testing occurs repeatedly for a question that has already been asked and answered (ie. Is the patient reliable and forthcoming), this testing is unnecessary and not medically justified. Health care practitioners who have has a means for financial gain by ordering this testingrisk being evaluated for fraud and illegal kickbacks. When a prescriber who also has a financial interest in a lab uses opioid therapy to lure people into getting repeated testing it is unethical and criminal; this form of greed is being evaluated by many individuals across the country. The U. S. Department of Justice is cracking down on private labs that investigators say offer incentives to doctors to frequently refer patients for lucrative testing.11
Motivation for Testing
In evaluating UDT testing, one must question the motivation for ordering tests. If the testing ordered financially benefits the tester, and there is no clear reason for the testing to be ordered, then the financial gain from the actual testing is fraud in the guise of medical care.
Some unscrupulous prescribers are abusing urine drug testing to defraud patients, insurance companies, and the U.S. government. When evaluating urine drug testing in pain management, here are six red flags that may indicate fraud:
- Qualitative and quantitative urine drug testing on nearly every visit to a physician’s office.
- Urine drug testing occurring more than once a year.
- A urine drug testing lab located in a physician’s office.
- A urine drug testing lab is owned or they have stock in a lab.
- Patients are told they can only use one lab for testing.
- For people with government issued insurance, diagnostic testing payments of over $500 for a patient visit.
Dr. Anthony Guarino is a recognized pain management expert witness and a celebrated clinician, teacher, author and researcher. His interest in pain management began during his undergraduate work at Yale University, and developed further during graduate studies in religion at Yale Divinity School. He completed a medical degree at the University of Maryland, an internship in medicine at Sinai Hospital in Baltimore and an anesthesiology residency and formal training in pain management at the Johns Hopkins Hospital. Dr. Guarino serves as director of pain management services for Washington University at Barnes Jewish West County Hospital where he evaluates and treats not only the area of pain but the whole person. He can be reached at firstname.lastname@example.org or 314-580-4609.
- Webster LR, Dove F. Assessing patients for the risk of opioid abuse. Avoiding opioid abuse while managing pain. Sunrise Press. 2007:87-109.
- Jamison RN, Serraillier J, Michna E. Assessment and Treatment of Abuse Risk in Opioid Prescribing for Chronic Pain. Pain Research and Treatment Volume 2011 (2011), Article ID 941808, 12 pages http://dx.doi.org/10.1155/2011/941808
- Webster LR, Dove F. Assessing patients for the risk of opioid abuse. Avoiding opioid abuse while managing pain. Sunrise Press. 2007:126.
- http://www.paincenter.pitt.edu/sites/default/files/Manchikant%20-opioid%20prescribing%20part%201.pdf – pp 38-40.
- Martell BA, O’Connor P, Kearns RD…Systematic Review: Opioid treatment of low back pain; prevalence, efficacy, and association with addition. Ann Inter Med 2007:146:116-127.
- Alltucker K. Labs, doctors scrutinized over lucrative drug tests for pain-pill abuse. The Republic. December 26, 2015.