My Story: Physician Perspective on Urine Drug Testing

My Story: Physician Perspective on Urine Drug Testing

Editor’s Note: Recently, columnist Kurt W.G. Matthies, who is a pain patient, wrote a piece for the National Pain Report about urine drug testing. It inspired Dr. Radnovich to share his thoughts as a physician. 

One of the most confusing and contentious areas in pain management is urine drug testing. Or is it monitoring… or screening? We cannot even get our terminology consistent. There buckets of other reasons: conflicting guidelines, state laws, the clinical value is not fully determined, the purpose for testing seems to be based on mistrust, and doctors sometimes are uncertain of what the results mean.

There are 3 types of urine analysis (UA) generally used: 1. Immunoassays 2. Analyzers and 3. Molecular analysis – with any other following easy to pronounce technologies: Gas chromatography/mass spectrometry (GC/MS); liquid chromatographyspectrometry (LC/MS/MS) or high performance liquid chromatography (HPLC).

Probably the most common are the Point of Care cups (POC). The fancy term for these is ‘enzyme mediated immunoassay’ (EIA). These are the little cups with the strips that change color and are similar to urine pregnancy tests. They are the least expensive, and least accurate, of all the urine monitoring tools. To use these, the doctor needs no special equipment or training.  They are designed, and should be used, as a cheap initial check only. Medicare pays about 20 bucks for this. POCs are appropriately called ‘urine drug screens’.

The second type is the analyzer. Instead of a cup that has markings that change in the presence of chemicals, this method uses a device (usually referred to as a ‘desktop analyzer’) that assesses the urine specifically for a wider range of chemicals; for example this machine can detect alcohol and POC cups cannot. You (or your insurance) may get billed several hundred dollars for this procedure. While the doctor needs a special certification and a lab tech to perform these UA, this is still considered an initial screen.

The idea behind the urine drug screens is to not waste money on expensive tests if they are not needed. If the screening shows expected results, there is no need to do another test. But if the results are not as expected (say, there is no hydrocodone, but there are illicit drugs) then the true urine drug ‘test’ is needed. Urine screens are not accurate enough, and are not designed for important clinical decisions. But it happens all the time.

LC/MS, GC/MS, HPLC is the final type of urine test. It is really expensive and really accurate.  It can detect, on a molecular basis, virtually all the chemicals in your urine. While the first 2 types of tests are usually performed in the doctors’ office, these are sent out to a lab. This is the test that you got the $2,000 bill for. This is the test that should be used to confirm the results of the screening tests (analyzer or POC).

The frequency of urine monitoring should be based on a patients risk for having problems; low risk patients should be monitored less frequently (perhaps once or twice a year), higher risk patients more frequently (as often as every refill).

But the frequency and choice of assessment is only part of the picture. The ability to interpret the results is more important.  And some clinicians are not accurately interpreting the results and thus making uninformed decisions. This is the crux of the problem.

So what can you do if think you have been the victim of misinterpretation of test results? It is almost impossible for a patient to change a doctors opinion, particularly after a course of action has been chosen; but here are a few things you can try. First, get a written copy of the results. You would be surprised how often results are simply misread. If the results are hand written, chances are you had only a POC cup. If so, get the ‘package insert’. This is easily obtained online or directly from the doc’s office. The package insert will tell you what drugs the cup can and cannot detect. If you were discharged from the practice, you will need to remind the doctor that these cups are intended only as initial screening tools. It will say something like that in the package insert. If you cannot talk directly to the prescriber, you might try a brief note and a copy of the package insert. Also, you can try to give the doc one of the articles that are linked below.

If the test was a LC/MS, GC/MS, HPLC, try calling the company’s sales representative or the lab’s medical director. Either may be able to help educate the clinician. Again, you might try printing out one these articles and give them to your prescriber.

http://www.nhms.org/sites/default/files/Pdfs/UrineDrugTestingguide.pdf

http://www.painphysicianjournal.com/2011/march/2011;14;123-143.pdf

http://painmedicinenews.com/download/UDT_PMNSE2013_WM.pdf

Not to blame the victim, but it is fairly unusual to get discharged for a single inconsistent UA. In fact, the articles referenced above advise against a zero tolerance policy and discharging patients. Have you had frequent early refills? Has your medication use been increasing? These occurrences are not necessarily bad, but they may be adding to your doctors concerns that, in addition to the UA, resulted in discharge.

As an absolute last resort, you might consider the nuclear option: filing a complaint with your state’s medical board. This will almost certainly not get you back in the practice, but it could result in the doc getting some education forced on him, and may help the next chronic pain patient.

Has this happened to you? Has ANYONE been able to change the doctor’s mind? Does anyone have any other suggestions?

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There are 4 comments for this article
  1. Sandy at 11:09 am

    OH Lawd…this has been both a nightmare and in the end a trust builder.

    Let me explain:
    Started to have problems regarding UAs in clinic around the time the Booth backdrop/background test was sold as ‘the answer for pain doctors’. It is an IN CLINIC UA. First the POC, then if results aren’t clear they use this other method in clinic. Problem is doctors were sold a LIE and countless patients suffered. It isn’t an answer let alone *THE* answer; even a Fed appellate court said NO only UA sent to a lab or blood. Booth Backdrop? Was garbage, mostly. [**more info re: court’s findings at bottom of comment].

    Meanwhile there was a lot of mistrust being built between my doctor and I.
    We both had been left wondering what was going on! I’d show up negative [in clinic UA] and would get berated over it. [he has me in every 2wks first he said due to the negative tests and now he says due to dosage. If I turn down injections that makes one an abuser in his mind too. Patients have very little power over their disease when it involves chronic, incurable pain….] Every appointment would go like this:
    DR: “You know Sandy your dose is high enough you should show up positive for your medications – in clinic…” ME: “but it is coming back from the lab OK?” Doc: “It is coming back from the lab OK but your dose is high enough it should show in clinic – we are using the booth backdrop” Me: “The Booth what??” [I did my own research because I know I wasn’t abusing, diverting and had taken one 12hr and 1 ir that morning!! So I couldn’t possibly be alone – printed it out and gave him a copy too]

    Started to volunteer pill counts every appointment to show I had the right amount of medication. [he once dismissed me with a ‘that doesn’t mean anything…’] I was getting *angry* at the constant accusations. Simply because I was turning up negative in the clinic [poc] but ALL screens sent to the lab came back poz for my medication. Still he accused me and one day [he’s still my doc in case you’re wondering.] I stormed out of there straight to the nearby hospital. The entire street is filled with labs like Quest Diagnostics. I wanted a lab that had nothing to do with the one my doctor used and I wanted BLOOD DRAWN willing to pay cash to verify medication levels. The cost for me to privately pay for it was much cheaper than the lab tested – 2000$ UA. [are you doubly, triply sure about that one? Home kits for 35$ have lab confirmations that come with the purchase]

    The small lab which did blood only understood what I wanted. Enough blood taken to find out my prescriptions blood levels. Was fed up at my doctor berating me, telling me I couldn’t be taking them correctly if i failed the ‘booth backdrop test’ wanted to put his mind at ease, stop being accused of improper use of meds and prove the ‘Booth’ was a whole lot of bunk sold to doctors. Only truly sure way to know your patient has the meds in their system and at *the right levels* for dosage – is a BLOOD TEST, especially if the UAs were causing issue. 180$ cash would give me those results – only my doctor would need to send something over to them before they did the test. Why? No clue. Did he? NO. Why? I think because he felt bad. That request was fax’ed and marked urgent put on his desk just 3hrs after I had injections in my spine. He said he didn’t allow the request because it would have been far too costly [more along that 2k mark and insurance wouldn’t pay for it].

    Ok. Fine I told him but do not berate me about an in clinic negative v lab positive from same ua.

    Next visit this [hope to see used more broadly eventually] handy spit test came out. Well it wasn’t just to test saliva for my medications it was to test DNA markers that can show if a patient is a “fast metabolizer” — redheads usually are, my hair is more dark auburn than Viking Strawberry Blonde but assume it doesn’t matter. You know what he never did again? **Berate me on a UA.** In fact tone changed with me over the last 2 years.

    Was I some high risk patient? Did I have a poor past history? Absolutely not. Compliant without complaining. Knowing it was pointless to complain anyway. The only thing is
    did have previous poz for MMJ and that was first year with him. A grand total of 3 poz MJ UAs in 5yrs. We discuss it. No high risk behavior, not a drinker and never have been. No abuse, no asking for more or ever needed an early refill – extremely careful about theft too. The only situation where I would have to contact him but a police report would be supplied.
    ….but I digress.

    In 2014 he kicked out all the lab people in his office, he even got rid of that machine. Plus insurance companies left, right and center were not allowing him to TEST in office since he had such a high rate he was testing. 2015 he does basic POC, sends to lab and only once per month am I tested now.

    His trust in me seems to have come back – I am on the highest dose in his office ; which isn’t to say it is very high just highest he allows. But I am his longest lasting patient too. Despite all that and coming very close to leaving as a doctor who couldn’t trust me wasn’t a doctor I could work with but knew changing doctors simply due to UA wouldn’t fix my issue. Education fixed it.
    –15yrs CPP, 5yrs with him, female, short, normal weight.
    The metabolic testing is one way to justify my dosage; if or when questioned.
    It has other practical uses too like ADR [Adverse Drug Reaction] to see which drug/s would most likely give me a reaction.
    –Sandy A. S.

    **[a FEDERAL appellate court ruled, Booth Backdrop/background test isn’t the answer – only the lab and/or blood testing. The company who sold those convincing pain doctors that test in clinic would rule out who was who – patient or diverter/addict/abuser. And made it worthwhile to doctors? Would only have one more road to recourse – Supreme Court of the United States. So it’s a safe bet ‘booth backdrop/background’ now has the appropriate fine print.]

  2. Terri Lewis at 11:58 am

    Pharmacogenetic Testing and Opioids
    Tennille Collins, PharmD Candidate, Diane Nykamp, PharmD
    US Pharmacist. 2015;40(3):2326.

  3. Terri Lewis at 11:47 am

    Yes. I have an observation and a suggestion.

    Patient selection is an extremely important part of treating the patient with chronic, long term or intractable pain. Patient selection doesn’t stop with the question of whether or not one wants to treat the person in front of you or whether or not you are the right clinician. Patient selection includes selection of treatment protocol based on the characteristics of the consumer. The characteristics of the consumer are not dictated simply by the diagnostic label, the demographics, the payor sources, or their degree of pain – they are determined by whether or not one has a history of increasing pain or disease, impairment, disability and handicap. If indeed they have processed from simple impairment to disability and handicap without benefits derived from treatment, there is a REASON FOR THIS. That reason is often associated with the ability of the clinician to theorize a treatment intervention based on their understanding of the patient, the disease process in question, and the likelihood of benefit. Too often the clinician conceptualizes these patients from an acute treatment model, even in the face of advanced disease.

    With chronic pain, we are tempted to undertreat or overtreat based on assumptions and biases. Too often we fail to determine whether the patient is likely to benefit from the treatment protocol we have the most experience with. There is a reason why people do not respond properly to some oral medications and that is because they cannot metabolize them due to genetic predispositions in the CYP groups of liver enzymes. After observing the pain histories of literally hundreds of patients I have to wonder why we fail to employ this simple test BEFORE we issue prescriptions for opioids, ssris, anti-epileptics, etc.?

    The UDT assumes that all patients metabolize similarly and unless one uses HPLC at the beginning, one will never know what in fact the urine drug screen has truly measured. It is only when we have a better understanding of which patients are likely to benefit from certain classes of oral medications that we can then use the UDT properly to make determinations that supplement treatment decisions. Or, when we know that the available classes of medications are not likely to be effective, we can save ourselves from applying the dangerous fail first approach that requires tx without results or may create significant conditions of harm. Too many consumers are forced into fail first treatment applications which are far more expensive over the long haul than utilizing the CYP450 clinical test application.

    I have personally observed far too many consumers who are dumped as the result of improper patient selection that uses the UDT to confirm lack of or errant results. In my experience, the use of a pain contract, coupled with an uninformed clinician who uses the UDT to discharge a patient, is a dangerous and sometimes life threatening combination – for the patient. It puts them on a course of continued treatment error and may force them into the use of other people’s medications in order to get relief.

    One also has to consider the ethics of pain contracts and UDTs – is the patient operating at egregious levels of pain truly capable of giving ‘consent’ when the clinician witholds treatment until an agreement can be extracted, and without conducting the appropriate examination and clinical assessment to assure that ‘fail first’ is unlikely?

    The CYP450 is far underutilized in my opinion. We need to know much more about this because it tells us a lot of disease mechanisms in the glial cell activation system. And that is important for understanding the nature of pain and disease processes.

  4. BL at 11:44 am

    If your dr won’t reconsider treating you, putting a letter where the package in copied and made part of the lerter and having it put in your medical records may be a good idea. It can be very difficult if not impossible to find a new dr to manage your pain if your medical records have a bad drug test in them and that is why your dr discharged you. Also remember that other red flags like early refills and not taking meds as prescribed are also part of medical records. And most drs check their states Prescription Monitoring Program before prescribing pain meds. In some states it is mandatory.