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.
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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