Opioid Urine Tests Scare Away People in Chronic Pain

Opioid Urine Tests Scare Away People in Chronic Pain

Urine drug screening (UDS) has become a standard routine for monitoring people who take opioids and root out opioid abuse.  The problem is that these drug screenings are scaring legitimate pain sufferers away from future treatment, a new study shows.

The study, published in Pain Physician, found that drug screenings increase the chance that patients taking opioids will not return for additional treatment. Nearly one quarter (23%) who received a urine drug screening during their first visit to a physician did not return for follow-up care.  Not surprisingly, the no-show rate for those who tested positive for illegal drugs was highest – 34%.  The no-show rate for those who tested negative was a stunning 21%.  For those who did not receive a urine drug screening on their first visit, the no-show rate was only 10%.

According to the authors, “These findings were replicated in eight different propensity-score matched subsamples aimed at addressing potential nonrandom selection, as well as in within-subject analysis accounting for individual-level no-show propensity.”

The study was done by researchers at the University of Houston and the University of Texas Medical Branch at Galveston.  They conducted an observational cohort study of 4,448 clinic visits by 723 people who suffer with pain.

“Urine drug screening is a mainstay in informing physicians about potential aberrant behaviors on the part of patients on opioid medications. While there is considerable research on the value of UDS to the physician, there is little research on how it influences patient behavior,” the authors wrote.

“Taken together the findings support the view that UDS may, in effect, be deterring people who are at high risk for abuse (as indicated by a positive test for illicit substances) from further engagement with the clinic.”

The authors believe their study is a first step in better understanding the relationship between urine drug screening and its impact on changing patients’ behavior. They note that additional research is needed to drill down to an even clearer understanding of how monitoring opioid use affects the behavior of those being considered for opioid therapy.

The study can be found here:  Krishnamurthy, P., PhD, Ranganathan, G., MD, Williams, C., MD, & Doulatram, G., MD. (n.d.). Impact of urine drug screening on no shows and dropouts among chronic pain patients: A propensity-matched cohort study. Pain Physician, 19(2), 89-100.

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Authored by: Staff

There are 26 comments for this article
  1. Kerry McKelvey at 6:45 pm

    Kathy, I just read your situation about your negative udt and your stomach surgery etc. You have a situation that’s all too often missed by pain management practices. I urge you and everybody to go to practicalpainmanagement.com and enter your issue into the search engine such as cases of false negative udt or absorption issues with stomach surgery etc. Dr Forrest Tennant is the original pain doctor and has practiced AND STUDIED pain management EXTENSIVELY for over 40 yrs. He writes many thought provoking articles that really shows the difference between a pain specialist and a PAIN SPECIALIST WHO IS ALL ABOUT THE INS AND OUTS OF GREAT UP TO DATE PAIN MANAGEMENT THAT PROVIDES THE MOST EFFECTIVE PAIN MANAGEMENT POSSIBLE FOR EACH AND EVERY PAIN PATIENT NO MATTER HOW COMPLICATED THEIR SITUATION. There are other contributors who write very good articles as well for both the patient and the doctors who need to expand their knowledge. Anyway, he wrote an article I read a while back on some of the causes pain patients seem to require higher opioid doses than others or get no relief at all and some cases involved the stomachs inability to break down and/or absorb medications and especially long acting or time released meds i.e. bariatric surgery or other malabsorption issues. Then he also wrote on cases when udt’s can possibly show false positives or negatives. I believe your situation can definitely be explained in either or both articles! Some pain Drs are hung up on his name because they are lazy and don’t do the research on Dr Tennant themselves and hear from word of mouth who hear from word of mouth gossip that just comes with the job of practicing 40yrs in pain management and all its politics. He has treated the worst 10% of pain conditions that require treatment that doesn’t fit the norm. I go to that website when I want to catch up on the latest research or have a question. It’s not his website he’s just the editor and very generous in sharing his knowledge by writing many articles. If you want to hear some of his talks I suggest going to YouTube and watching them. You will immediately get the idea of why he is so special and is so loved by so many!

  2. BL at 11:52 am

    Kathy, talk to the surgeon that did your stomach surgery and ask him if he will write a letter to your pain management dr. If you’re threwing up this much due to the surgery, your surgeon should be able to explain it as well as offer your medical records as proof that you do have this problem. Any new dr will get a copy of your medical records from your last pain dr, so you need to get this straightened out. If you don’t, you may find it difficult if not impossible to find a new dr to manage your pain.

  3. Kathy at 3:39 am

    I have had conic low back pain since being in a auto accident 10 years ago in spite of having 4 surgeries. snyway, I take my pain meds unless I have to drive somewhere or take care of my grandchildren. I get tested every month and the last 2 months the pain lady said I tested negative for the pain meds I was given. I had stomach surgery the end of may and still throw up 2/3 times a day. I was kicked off the program for negative testing in December. I feel like the tests are wrong or the pain drug lady has it in for me because I do take the meds everyday.

  4. Dave at 3:36 pm

    @Jean Price- Lincoln wrote- He can criticize, who has a heart to care.
    I admit to being hard nosed and judgmental- and sometimes I dont give people a full and fair chance. But frankly, I think its fair to say we do judge others-its part of being human. And what would the world be if we did not share our thoughts and emotions when it comes to suffering? It would be brutal and short-lived- as Hobbes indicated.
    And when it comes to the suffering of others(as I do not have any physical pain condition) I do feel it ex visceribus and do not believe judgment and criticism is morally wrong. As Roosevelt wrote- if there is one thing worse then a bully- it is those incapable of moral outrage. Too many in government and the health care industry need to hear about being wrong and their moral insensitivty to others. You, are of course free to judge my judgments and moral outrage- i dont mind a healthy exchange from someone whose values are different from my own- i believe in free speech and debate that is uninhibited robust and wide open.
    I think urine drug tests are an abomination and i think some commentators in this regard are insensitive to the treatment burden, stigma, and fundamental unfairness of udt-and those supporters of udts engagement with the issue is superficial.
    I have found most people are quite thick skinned when it comes to criticism as they usually suffer from identity foreclosure- so they usually just ignore criticism.

  5. Alissa at 1:25 pm

    No Name,

    Honestly, I don’t think you need to get involved. The only thing you may consider is advising your loved one that getting caught doing what she’s doing will certainly result in an end to her treatment. If you report her, it will result in an end to her treatment and strife in your family. Until you’ve been in pain every day, you can’t know what an impact it has, or how important it is to get effective treatment. You don’t want to get involved in taking that away from her. If she gets caught, you can’t be held responsible. The only duty I feel that you have is to be supportive of helping your family member become pain free.

  6. BL at 12:57 pm

    If you aren’t doing something you shouldn’t be doing, then you have no reason to fear drug screens. Whatever your objections may be to drug screens, when/if the time comes and you have to have the pain meds to do basic things, then you accept the drug screens as part of being a chornic pain patient in 2016. If you have problems with it and don’t continue treatment, then you don’t need the pain meds as badly as you think you do. The whole point of drug screens is to find the patients that are abusing their meds and not going by the rules and they seem to be doing that.

    No name. Please, in order for your family member to pass a drug screen, the person that they take the urine from also has to be taking the same pain meds. People like your family member are one of the reasons it is so hard on honest chronic pain patients now. Even if marijuana was legal in your state, it is doubtful that your family member would have the ok from their dr to use it.

    Either your family member is giving the pain meds that they are prescribed to the person that she uses their urine or your family member is lying to you. Personally, I hope your family member gets caught soon.

  7. Shirley Hinton at 10:39 am

    For me it’s like a rocking chair , moving back and forth. But not going anywhere . Waste of money..and they know it ..it’s pc only….that’s it unless your a wholesale heavy duty drug user .. I have never met one , not ever . It’s insulting to have to take one , insulting ! Ridiculous .
    Pain meds do one thing. Gets rid of pain ..is that now a crime? Who in their right mind would go through this on purpose ? Really folks .. its ridiculous to treat people this way .Shows how little we know. To treat patients this way because through no fault of their own have chronic pain .

  8. Jean Price at 9:59 am

    Dave…I hear a lot of frustration in your comments….with the pain care system and physicians who work under it! I think we are all angry and frustrated at the current state of affairs in the treatment of people with chronic pain, and we should be upset about it. Anger is something useful to help us define our values, and it can be a catalyst for taking actions to help bring positive changes. When we live with physical pain on a daily basis, most of us have difficulty dealing with the additional pain of unhelpful, judgmental doctors and broken health care systems. I get that! What I’m struggling with is your not so kind comments to someone I feel supports us in our battle to get the care and medications we need. Actually, even if he didn’t, there is really no reason to verbally attack someone with a different opinion. We each have a right to our own opinions, yet no one has the right to judge others for theirs. In the heat of the moment, I felt like you were sort of rude…and I guess I think you’re a better man than that. Your comments about the problems are really on target and compassionate for those of us in pain. Yet, your message gets lost in the attitude of the delivery. At the risk of sounding judgmental myself, I really wanted to take the time and energy to reach out to you because I’ve been there too! And I found my information wasn’t received because my anger and frustration spoke louder! If I have offended you, I sincerely apologize. It was not my intention. I just wanted to share some hard fought for information that might help you communicate in the future, especially with health care providers! Blessings, Dave

  9. Dave at 8:52 am

    Mr Lawhern- my apologies for mislabeling you. I did read what I thought were your writings on orofacial pain and psychosomatic illness.
    It is good that nonprofessionals- the great unwashed- involve themselves in pain care- for it affects so many people and in different ways. And as the saying goes- inquiry is not obligated to the words of authority. We should question common practices and beliefs- for the sake of better care- for as we know- pain care is very inadequate for too many people. And experts seem to lack an inspiring vision and energetic plan to improve pain care.As Heraclitus., Bernoulli, and Paracelsus understood- nature doesn’t give up her secrets too easily. We who are not pain specialists are very much needed to provide the counterpoint to the received views. And we must judge and question current practices and call for much better treatment of people in pain. If we don’t do that- then, I believe, pain care will improve at a very slow and petty pace.

  10. Richard A. Lawhern, Ph.D. at 5:41 am

    A note for Dave: You’re entitled to hold and voice your opinion. But please be advised: I am not a medical practitioner of any sort. Though I have earned a doctorate in systems engineering, I am medically as much among the “great unwashed” as you identify yourself. I’ve educated myself over the past 20 years on the medical literature of chronic face pain, in order to support people suffering with such afflictions — including my wife. I’ve also written widely on behalf of chronic pain patients, debunking the mythologies of mental health professionals who casually justify the misdiagnosis and abuse of people in pain, by applying mythological labels of “psychosomatic” medicine. If you bother to research my name, you’ll find a hefty profile of this work of support, on the Internet.

    The discussion of this thread illustrates the messy realities of the lives of chronic pain patients. No two people are fully the same. Many feel demeaned by the attitudes of some physicians who write them off as druggies or head cases. Yet one must also recognize and address the real problems created by drug-seekers who do not suffer chronic pain, but who try to game the system to feed their addictions. These two realities co-exist. To solve either one, both must be addressed. I suggest that both physicians and their clients need to go through the educational process and participate in the solutions, whatever they ultimately turn out to be.

  11. Peggy Baxter at 7:37 pm

    I believe that it’s how chronic pain patients are treated by the medical staff! Who wants to be looked down on and treated like an addict or a criminal! I have never failed a drug test but a friend had one come back positive for everything! She was humiliated especially when the doctor refused to retest her. She even offered to have blood drawn to prove it was a lab error! He still refused! The doctor’s around here are taking everyone off pain medication. We are told to just deal with it! It’s torture and unnecessary!

  12. Kerry at 5:34 pm

    When I was tested randomly by various pain doctors over many years was to show I WAS taking what was prescribed to me and not selling it. So it was a good thing to test positive for the opioids. Bad thing to test positive for THC. My last pain doctor that did this testing told me it was part of showing DEA his due diligence in part of verifying he was treating valid pain patients. I believed him at the time because it was when they were hitting pain practices in droves and making examples out of legitimate pain doctors who were no where close to the pill mills at the time. I agree with the others that this study may have had good intentions however I would bet the urinalysis wasn’t the driving force of the non returning patients. Negative attitudes of pain doctors along with lack of focus on the pain condition vs patients were just there to get opioids becoming the focus of the appointment that just drives pain patients crazy. What really is the purpose of many pain clinics today anyway? Not to effectively treat pain that’s for sure.

  13. Jean Price at 3:28 pm

    Cynthia, no apologies necessary! You are allowed, like the rest of us, to question things. That’s not a deficiency, dear! It’s part of being human. For me, the testing is an annoyance…because there is no attempt to assess the actual NEED for this. I have a high value for only doing necessary tests for a patient’s care. And I also have a high value for not incurring additional costs for my care, especially when I have a long term, positive, compliant relationship with the doctor/clinic. The cost of insurance is tied to the amount they pay in claims, and they are paying all or part for a great many of these. I truly feel this also continues to support looking at two separate problems, pain and addiction, as one. It’s not true and it’s offensive. Plus it does justice to neither. Are people who have positive drug tests and don’t return contacted or followed up? I don’t think so. Are the ones who were negative and didn’t return contacted to see if they are okay and find out what happened? Again, I don’t think so. Therefore, what benefit does this really have? Perhaps a few people didn’t get to manipulate the doctor for the meds they didn’t need in the first place for pain. But does that justify driving so many others off because they felt judged and didn’t have the strength to deal with that on top of pain? So, as both some one who worked in health care and a person who has lived with pain for over 25 years, I just don’t see the sense behind this, or any true benefit. It’s fear based, not care based. And I don’t think it addresses health, physical or mental.

  14. No name. Please at 3:18 pm

    My family member is treated by a pain management doctor who requires urine tests on every visit. Since she is a heavy pot user in a state where marijuana is not legal she doesn’t want it to show up in her tests. So, she has her daughters, granddaughters and even her husband void in a bottle, which she then sneaks in and substitutes as her own. Wouldn’t the test show when her husband had provided the specimen? What are the legal ramifications? Do I have a responsibility to report this? I only have grapevine information. She has never asked me to do this for her. I worry that people doing things. Like this make it harder for everyone. Thank you for your thoughts.

  15. T. Mason at 2:53 pm

    First, the drug screen helps keep people honest. I have never been offended or nor frightened when whizzing in the jar.
    Secondly, testing positive for opiates or any other scheduled drug you have been prescribed eliminates you from a pool of people that would get the medicine to sale on the street, trade for other drugs etc. Furthermore, the amount can and usually quantitated to determine that a patient is following the dosing schedule.
    I do feel the CLIA waved dipstick test is sufficient and only cost about $5 dollars to purchase by the clinic. I do think routine GC/MS/MS or LC/MS is too costly. There is no money is doing the CLIA waved test. Without a doubt drug screen tests by outside testing labs by elaborate means and expensive is a money making adventure. The outside lab can differentiate between amphetamine and methamphetamine and can determine if someone snorted cocaine or smoked the freebase form. They can even tell if you drank alcohol with these drugs. The standards they use are metabolites so there is no beating the test. This is forensic chemistry at its finest.
    These things I know because I myself am a research chemist. I typically run GC/MS but the compounds I analyze are from the polymer synthesis lab where I work.
    The drug screening process is required not only to protect the patient but the pain management practice and their employees. They have a job to protect.
    I depend on my pain medicine to make it thru my work day. I would not in any way jeopardize my relationship with the doctors and nurses helping me by doing something foolish as taking someone’s medicine or giving my medicine to anyone.
    It is a tough world out there and we must play by the rules.

  16. Cynthia A Smith at 2:53 pm

    Thank you kindly for those that took their time to enlighten me. My PM DR does UDS approx every other month. I believe this is a mandate. I pay 20% of $60 per UDS. They do only take referrals from specific Drs. They explained that was to reduce the amount of ‘drug seekers’. I had never been to a PMDR prior and was a bit traumatized by the ‘drug contract’ or whatever it was called. My fear stemmed from messing up and doing something wrong to get me ‘fired’ from the practice. Had never heard of that before either.
    They did actually explain how to ‘protect yourself and your meds’ from being victimized for your pharmaceuticals. I must say it was pretty scary… And again all new to me.
    I agree it is a large cost for chronic pain (CP) individuals, insured or not, to burden. It also feels invasive and one more hoop to jump through for treatment. Wow! I would give anything to be able to jump again!
    Which leads me to my last point (I am sure your glad), who in their right mind would sign up to be a CP individual. We are a voice no one hears, considered useless, substandard, waste of people’s time, taking up too much real estate and assistance, and finally using up oxygen. Pretty much sums up the attitudes I have encountered in the last year, my first year of this messy system. I guess it is time to be actively heard and to demand our rights and to be treated appropriately. Wishing you all well! Thank you!

  17. Dave at 2:15 pm

    Dr Lawhern- youre promoting the received view and the occupational strategies of your colleagues-my, how self-serving. And, I of course, am not qualified to have an opinion- because i have no training in medicine. But frankly urine testing is an abomination. Its demeaning, unnecessary- and needles too say too many false positives get people in pain blacklisted and mistreated. It violates prinicipilism and damages an already tenuous doctor patient relationship. It is regressive for it doesnt promote the generative capacity of people who seek doctors care-instead it promotes a continuation of the medicocentric discursive imperialism of your colleagues- many of them who have fought against education in pain care- and who fail basic test of musculoskeletal knowledge( despite the fact that most painful conditions are musculoskeletal), many who underestimate peoples pain and overestimate the value of their interventions. I think the American public has had enough of the invertebration of people who are labeled as “patients” by your colleagues. We understand that you believe you stand in the light of nature- but that doesnt mean we are stuck in Platos cave.
    It is interesting that some anti-convulsants are seen as addictive- but no urine drug testing is required for them.
    It is regrettable that doctors continue to believe they are free to treat people in pain any way they chose-and we see the results- with ever- increasing prevalence of arthritis, neuropathic conditions, and migraines,, stigmatization of people in pain with terms like “catastrophizers. Obviously docotrs you believe in eliminative materialism and prescriptivism. Moral an mental laziness in medicine is common.
    Maybe our health care system would be serves better if doctors were required not to miss that hour lecture in pain care and learn the meaning of caritas.
    But Im sure your dorsolateral prefrontal cortex and basomedial amygdala are methylated for some assertion and rejoinder from this unwashed citizen.

  18. Richard A. Lawhern, Ph.D. at 1:22 pm

    Peggy, you may want to do a Web search for the “Top Doctors” list published each year by US News and World Report for the US. The listing is compiled by medical specialty and US State, and neurology is one of the specialties (I for get if pain management is). It is compiled by surveys sent to over 50,000 doctors to whom they would refer a member of their own families, in the various specialties.

  19. Richard A. Lawhern, Ph.D. at 1:20 pm

    Cynthia, from what I can determine by talking with chronic pain patients, some of them feel profoundly dis-believed and invaded when medical practitioners demand urine testing as a pre-condition for being treated. When I read the brief study report, I didn’t see any indications that the investigators bothered to analyze or describe the counseling provided to patients before they were asked to do urine tests. If they weren’t informed properly of the positive reasons for such tests, then it would be entirely understandable if some of them (23%) failed to show up for additional appointments.

    The study also found that a third of patients who tested positive for opioids on the first appointment didn’t show up for additional appointments. That isn’t surprising. A lot of addicts doctor-shop until they find one that doesn’t ask questions they don’t want to answer. In my opinion, what may be needed is appropriate counseling and education for both groups.

  20. Jean Price at 1:11 pm

    Testing can be a touchy issue for patients. I have always questioned the validity of this policy being part of an appropriate treatment plan for people with chronic pain, since it feels more like judgement and policing than anything! Perhaps that’s because it’s not really necessary for me personally, and many others. But also because I believe doctors have lost the art of discernment and the practice of a hands on exam when evaluating patients. I agree that more research needs to be done on what this testing actually achieves, especially a comparison component based on the physician’s pre-test opinion of whether it was necessary for that patient at that time! My pain clinic staff did test me on my first visit, and although I partially understood, I was still humiliated. I would never consider substance abuse as a healthy choice for pain relief. And yet I feel this test is based on the assumption that I or ANYONE seeking help for pain would either want drugs to sell, or would have a habit of self medicating with illegal substances or medicines obtained illegally. What irritated me more was having a random test a year after I had been going to the clinic, with no history of non compliance whatsoever! And these tests, which I didn’t need for my actual CARE, costs me over $300 dollars! What a waste of my resources ….AND those of Medicare, since the original cost was over $1200! It continues to annoy me when, after five plus year with a “spotless record”, I still have to submit to random tests. It’s a waste and also a silent label! I feel doctors are forced into testing because it’s mandated and because they have become very wary of the system that blames them for a patient’s choice to overdose and/or mix legally/illegally obtained drugs which can cause injury/loss of life. So now, MY patient care reflects more on curtailing drug addiction than it does on relieving my pain, even though I am compliant and only want help to lessen my chronic pain—so I can be more functional and have a better quality of life. And the majority of people with pain are just like this, too. Again, it is kindergarten rules! Johnny talks, so all of us miss recess! Yet this has much bigger consequences than unfairly missing recess! All you have to do is browse the comment section of organizations who support people with chronic pain to see the emotional toil it takes, and the frustration and the abandonment people with life-limiting physical pain are feeling. In reality, how hard would it be to influence these tests to show you were using your meds when in fact you sold most of them? If I can think of this, and it’s so contrary to my moral code and my pain needs…how many of those who are merely manipulating the system and seeking drugs to sell or to use themselves because of an addiction would think of it too?! So what does this really achieve? In attempting to positively counter drug abuse, many other people and their care issues have been sacrificed. And I doubt the addiction problem has been impacted. I propose changing the test to only those the physician feels may have other issues outside of pain. And to change the mindset of assigning blame to our physicians for the problem of addiction/suicide, especially when their prescribing practices are solid. Although a very few do stray outside of legal and moral practices, most strive to give their patients with chronic pain appropriate care and sound treatments and follow up, and they partner with us to achieve this. And as for that 21% of people who were in pain and had negative abuse results yet never returned, I think they were failed by a system that humiliated and devalued their struggle to live as normally as possible with pain. It’s really very understandable, pain is hard enough… sometimes we just don’t have the energy to stand up for ourselves, and we are sensitized from all the erroneous labeling and negativism about pain. Sad but true. It’s time to address the fallacies and return to compassionate, appropriate care! I’d vote for that! This would be the only sensible, the only humane thing to do.

  21. Donna at 12:47 pm

    UDS do not bother me per se. It is the attitude of the people at the pain clinic I see. They give an attitude as if they expect me to fail it (never have). Also, my insurance will no longer pay 100%, only 80. I already struggle to pay the 50 dollar copay. Perhaps they should be asking why the number is high. It could be the way we are treated, costs or the embarrassment of it.

  22. Peggy Baxter at 12:19 pm

    Do you have a list of doctors that treat chronic pain patients?

  23. Cynthia A Smith at 11:42 am

    First, please excuse my deficits. Due to a disease process of my brain, sometimes I am unable to retain or collect the information to critically think. I am also a new chronic pain sufferer, due to an incurable disease. With that said, I am unable to dissect or understand why many find difficulty with standard urine screening. Is it the invasion of privacy?
    Again please excuse me for my deficits.
    If anyone is willing to be of assistance to explain this to me I am very obliged. My very best regards to you each!

  24. Richard A. Lawhern, Ph.D. at 11:16 am

    I find myself wondering whether this study should be performed again with one group of patients counseled on the reasons behind urine testing in a standardized physician presentation, versus a second group handled in whatever manner has been used previously in the practice. I have supported chronic pain patients for 20 years in peer-to-peer online forums. My strong impression is that most would not object to urine testing if it was first explained to them in a way that is non-stigmatizing and emotionally supportive.

    The undeniable reality is that some people do come to pain management physicians seeking drugs to get high or to stave off withdrawal symptoms. For clients who test positive for elevated levels of opiates, some additional process of counseling and oversight would seem to be indicated, to assess whether they are valid pain and then to assist in referring them to addiction withdrawal therapy. I believe that most valid chronic pain patients can be led to understand this need as an element of “due care and oversight” that ultimately protects them from arbitrary or ill-considered denial of medications they need to function.

    Sincerely,
    Richard A. Lawhern, Ph.D.
    Chronic Face Pain Patient Advocate.

  25. Mark Ibsen MD at 11:12 am

    Uds COULD build trust.
    If it leads to a useful conversation.

    If patients just get fired…..