Urine Drug Test For Chronic Pain Patients – Another Perspective

Urine Drug Test For Chronic Pain Patients – Another Perspective

Editor’s Note: Terri Lewis is a frequent contributor to editorial content for the National Pain Report. She is a patient advocate and educator and a parent and daughter of persons with chronic pain. She is a PhD in Rehab counseling and currently teaches rehabilitation counseling to allied health clinicians, physicians, and counselors in Taiwan.

I have an observation and a suggestion regarding recent dialogue about urine drug testing.

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 withholds 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.

 

Have you taken the Patient Survey on the National Pain Strategy issues that Dr. Lewis is conducting? She will share the results with the National Pain Report. 

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Authored by: Terri A Lewis, PhD.

There are 4 comments for this article
  1. Thomas Bresnahan at 7:55 am

    I would have to say that there is a total and complete ignorance as to why patients are tested. It’s all about control and the clinician covering their back side from a system that penalizes those who suffer from Chronic Pain. Urine screenings are done every month in the vast majority of Pain Management Facilities. They are done to see if a patient is using illegal or non prescribed medications! That’s it, No other reason!! If the Clinician wanted to test for the effectiveness of the medication they are prescribing they could or would utilize a test such as the one offered by YouScript.com
    It’s a mouth swab that tests an individual’s DNA and provides a lifelong assement of that persons DNA makeup for clinicians and pharmacist. Urine Screening and “Pain Contracts” are just a way to control the patient to what the clinicians believes is best. It has Nothing to do with what the patient believes is best for their treatment. In every case pain contracts are pre printed and NOT individualized. We need to quit sugar coating the system that is leaving many left under treated or untreated by those who have never experienced the first hand agony of pain!

  2. DRMINDY at 12:08 pm

    I found your article very interesting having recently been the victim of one such “unethical” UDT. After having been a patient at the same pain clinic for the past 5+ years and never having failed a UDT during that time, I was shocked to receive notification last February from my insurance provider that I had undergone over $2500.00 in “lab work” on a date when I wasn’t even at the pain clinic! Waiting for the bill to arrive outlining the details – again, I was shocked to read that my current provider, a new younger nurse practitioner – newly assigned to handle my care – had ordered an additional UDT encompassing 35 drugs that ranged from everything I’d ever been prescribed over the 5 year period to heroin and PCP totaling over $2500 exactly one week to the day that I had taken my standard, required and “random” immunoassay UDT (having just completed my once annual UDT at the end of October being a “low-risk patient) during my routine visit!!

    I later learned that it was most likely due to a “false positive” for methadone and a negative for Flexeril – which is normal for me as it is only taken “as needed” and not filled monthly but rather once about every 4-6 months. The negative Flexeril has shown up previously on other UDT’s and not considered a red flag as I do not take it daily. My insurance company led me to believe that were not going to be paying for these charges and took over 3 months to pay at reduced negotiated rate.

    I just recently learned from doing some major research that one of my medications, Nucynta (Tapentadol) can cause a “false positive” for methadone on immunoassay UDT’s from the University of Maryland’s School of Medicine and that this knowledge has been around since 2013!

    Don’t you think a clinic that specializes in pain medicine should have had this knowledge that’s nearly two years old?! Don’t you think the lab that came back with the false positive for methadone should have included this information on their report?? Don’t you think that this nurse practitioner should have at the very least tested for methadone instead running tests for “35” other drugs running up a bill for over TWO THOUSAND DOLLARS!! Don’t you think she should have checked with some slightly more knowledgeable about this type of testing before she ordered this full panel? Or maybe she did?!

    I guess I should be just be thankful that I was fully vindicated when everything came back NEGATIVE and there were no errors on the 2nd report! But I just find this as close to unethical, abuse, negligence and fraud when now my insurance company has paid the claim and I am now being billed for the remainder! Not to mention that my pain doctor immediately removed the nurse practitioner from handling my care without giving me a reason and has been pushing injections, spinal cord stimulators, genetic testing, expensive treatments, and a skin nerve fiber biopsy in the months since March! In addition, he has now decided in his wisdom that after successful opioid therapy for the last five+ years, all of a sudden, my body deserves a break and he will be removing all opioids from my treatment plan! Even though I’ve not requested any increases in my medication and not complained of increased pain levels?! But I have repeatedly turned down his insistence that I “consider strongly” spine injections and spinal cord stimulators for my Arachnoiditis.

    Yes, I agree that the UDT’s and the contracts mandated in a pain clinic are less than ethically used when they include wording that states “you must agree to abide by your providers recommendations for treatment” . When you are seen as not in agreement, you are out of compliance. And that gives your provider grounds to release you from care. Don’t sign the contract and you cannot receive care. Essentially, the patient has no voice and has no rights as these contracts are required by state regulation.

  3. Ingrid H. at 11:36 am

    Thank you for such an informed and enlightening article!! It is my belief that all doctors who treat pain, (or at the very least if they encounter a patient who is unresponsive to pain medicine), they should be required to utilize the genetic testing of Cytochrome 450 to determine what type of metabolizer the patient is. This is especially important in regards to CYP2d6 ultra rapid metabolizers or poor metabolizers. They need a personalized medical regime, as they don’t fit into the “Standard of Care” being suggested by the Medical Boards, FDA, Medicare, etc.