Urine Toxicology Testing in Chronic Pain Management

Size: px
Start display at page:

Download "Urine Toxicology Testing in Chronic Pain Management"

Transcription

1 Global reprints distributed only by Postgraduate Medicine USA. No part of Postgraduate Medicine may be reproduced or transmitted in any form without written permission from the publisher. All permission requests to reproduce or adapt published material must be directed to the journal office in Berwyn, PA, no other persons or offices are authorized to act on our behalf. Requests should include a statement describing how material will be used, the complete article citation, a copy of the figure or table of interest as it appeared in the journal, and a copy of the new (adapted) material if appropriate CLINICAL FEATURES Urine Toxicology Testing in Chronic Pain Management Edward J. Cone, PhD 1 Yale H. Caplan, PhD 2 1 Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD; 2 Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD Correspondence: Edward J. Cone, PhD, 441 Fairtree Dr., Severna Park, MD Tel: Fax: edward.cone@comcast.net Abstract: Treatment guidelines for chronic noncancer pain recommend opioids for carefully selected, closely monitored patients. However, many primary care physicians have a limited understanding of urine toxicology testing, which is the standard for monitoring opioid therapy. This article describes the technical aspects of urine toxicology testing and provides recommendations for monitoring patients to maximize the safety of opioid therapy. Articles were identified in PubMed, Medline, and EMBASE (January 1980 November 2008) using the search term opioid in combination with the terms urine toxicology, compliance monitoring, abuse, and diversion. Articles characterizing the pharmacology of individual opioids and practice guidelines for the management of chronic pain were also identified. Articles selected for inclusion discussed technical aspects of urine toxicology testing, clinical aspects of monitoring, and issues related to abuse and diversion. Urine tests can detect prescribed and illicit substances that are present above a specific threshold, but they provide limited data about the source, dose, or route of administration of substances detected. Effective monitoring requires careful test selection, an understanding of pharmacologic and metabolic factors influencing test results, and awareness of methods by which patients who are substance abusers may tamper with test specimens to escape detection. All patients prescribed opioids, not just those considered at risk for abuse, should undergo urine toxicology testing. Given its inherent complexities, effective urine testing requires close collaboration between the primary care physician and a reliable laboratory to develop an appropriate test protocol for each patient and to interpret test results. Keywords: opioids; chronic pain; urine drug testing; compliance monitoring Introduction Opioids have a well-established role in the management of postoperative 1 and cancer pain 2 4 and are now recommended therapies in the treatment of noncancer pain, including chronic pain in the elderly, 5 acute and chronic back pain, 6 osteoarthritis pain, 7 and other chronic pain that does not respond to other therapies. Despite guidelines supporting judicious use of opioids, the potential risks of abuse, addiction, and diversion have led to reluctance on the part of some physicians to prescribe them. 8,9 To reduce these risks, recent American Pain Society (APS)/American Academy of Pain Medicine (AAPM) guidelines recommend careful monitoring of any patient prescribed an opioid for an extended period (eg, 30 days) for the use of opioids in patients with chronic noncancer pain. 10 Monitoring methods include routine assessment of pain, function, and adverse events. Abuse-monitoring methods include patient self-report, behavioral monitoring, and drug testing. However, patient self-report is often unreliable, 11,12 and behavioral monitoring also frequently fails to detect misuse. 13 Drug testing can be performed using different types of biologic specimens, including blood, urine, saliva, hair, and sweat. Of these, urine testing is the most standardized and widely used method. The APS/AAPM guidelines include a strong recommendation Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn e

2 Edward J. Cone and Yale H. Caplan for routine urine drug testing in patients who have a history of substance abuse or are otherwise considered to have a heightened risk of abuse. The guidelines further state that clinicians should consider periodic testing in patients who have no known history of substance abuse and no known risk factors, but the current evidence does not support a strong recommendation in this population. 10 Urine testing is noninvasive, is amenable to simple point-of-care and laboratory methods, and allows detection of many drugs and metabolites over a relatively long period. 14 Despite its utility, few physicians conduct urine toxicology testing in their opioid-treated patients 8 or are adept at interpreting results. 15,16 Given the increasing use of opioids, it is essential that clinicians know how to effectively monitor their patients compliance with therapy, and can detect abuse or diversion. To that end, this article provides clinicians with a basic understanding of the necessity, rationale, methodology, application, and interpretation of urine drug testing for all patients with chronic pain treated with opioid analgesics. We also discuss the potential benefits of routine urine drug testing in any patient receiving chronic opioid therapy as opposed to solely in patients with a history of or risk factors for abuse. Articles included in the review were identified in PubMed, Medline, and EMASE (January 1980 November 2008) using the search terms opioid, urine toxicology, compliance monitoring, abuse, and diversion. Additional references cited in the articles identified were also reviewed. Emphasis is placed on articles addressing technical aspects of urine toxicology testing, clinical aspects of effective patient monitoring, or issues related to opioid abuse and diversion. Articles on the pharmacology of individual opioids, opioid metabolism, and practice guidelines for the management of chronic pain are also selected for inclusion. Which Patients Require Urine Drug Testing? Careful Patient Selection Versus a Universal Precaution Approach The prevalence of chronic pain in the United States has been estimated at between 10% 17 and 25%, 18 with the rate increasing with age. At the same time, an estimated 19.5 million (8.3%) individuals aged > 12 years are current illicit drug users; this figure declines to 3% in persons aged 55 years. 19 Although the prevalence of substance abuse tends to decrease with age, chronic pain prevalence increases, resulting in substantial overlap of the 2 populations. In a recent systematic review, 1% of patients in opioid clinical trials with history of substance abuse as an exclusion criteria showed evidence of substance abuse or addiction during treatment. 20 However, in studies without this exclusion criteria, 5% showed evidence of abuse or addiction, and in studies reporting urine toxicology results, suspicious findings for opioids were reported in 20% of patients, and 11.5% of patients showed signs of nonopioid drug-related abuse. 20 These results suggest that clinical trials with carefully selected patient populations do not reflect the extent of abuse in the general population of patients treated with opioids, and urine screening may detect inappropriate use that is not identified by other means. Although sparse, clinical data suggest that urine testing may reduce the occurrence of substance abuse in patients receiving long-term opioid therapy. In a prospective study, consecutive patients on stable doses of morphine, oxycodone, methadone, or hydrocodone underwent random urine drug testing to screen for opioids, oxycodone, methadone, cocaine, amphetamines, methamphetamines, cannabinoids, benzodiazepines, barbiturates, and phencyclidine. The prevalence of illicit drug use was found to be 16%, representing a 27% reduction from the 22% prevalence reported in a population of chronic pain patients evaluated in an earlier study by the same investigators. 22 In a second prospective study, consecutive patients on stable doses of opioids were monitored using a more comprehensive protocol that included urine testing in conjunction with pill counts, periodic review of medications, and review of patient-provided medication information with treating physicians and pharmacists. In this cohort, prescription drug abuse was apparent in 9% of patients, a 50% reduction relative to the 18% prevalence reported in populations in 2 earlier studies by the same investigators. 24,25 The evident overlap between the populations of patients with chronic pain and individuals who abuse substances, coupled with the inherent difficulties in identifying at-risk patients using patient interviews and behavioral assessments 13,26 suggest that greater vigilance is needed to monitor patients treated with opioids. Given the potential to reduce abuse with routine monitoring as demonstrated in clinical trials, 21,23 we believe that urine drug testing should be standard practice for all patients treated with opioids for a prolonged period ( 30 days). This universal precaution approach to urine drug testing may not only reduce risk but also protect physicians from accusations of discrimination and prevent monitored patients from feeling stigmatized as having an exceptional risk profile. 92 Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

3 Urine Toxicology Testing in Chronic Pain Management Urine Drug Testing Defined The term drug testing can be misleading because it implies that an individual is being tested for the presence of all drugs. 27 In fact, urine tests only target specific drugs or drug classes and are designed to detect substances only when they are present above predetermined thresholds. The term drug screening can also be misleading because it is used somewhat inappropriately to describe all types of drug testing, whereas screening is used in forensic toxicology to describe use of immunoassay tests to distinguish specimens that test negative for a drug and/or metabolite from positive specimens. Drug testing is frequently conducted by the federal government, employers, and the courts to detect common drugs of abuse. Federal drug testing usually focuses on 5 drug categories: marijuana, cocaine, opiates (eg, heroin), phencyclidine, and amphetamines (amphetamine/methamphetamine). 28 Employer-mandated testing in the private sector may extend these federal 5 drugs to include methadone, oxycodone, oxymorphone, hydrocodone, hydromorphone, fentanyl, meperidine, propoxyphene, benzodiazepines, barbiturates, and other selected drugs. Detection thresholds for federal, employer, and forensic drug testing panels are set high enough to detect concentrations suggesting abuse, but they do not always detect therapeutic concentrations. For example, the threshold for opiates in federally mandated workplace drug screening is 2000 ng/ml. 29 The usual threshold for opiates in clinical monitoring is 300 ng/ml. 30 Thus, drug tests used for workplace applications may be inadequate for compliance monitoring in patients with chronic pain. How to Select the Appropriate Urine Drug Tests Point-of-Care Tests Point-of-care tests are single-use disposable devices employing immunoassay technologies that provide rapid detection and an opportunity for rapid clinical action. In most test kits, a color change indicates the presence of a drug and/or metabolite in the urine specimen. Usually, this is a nonquantitative all or none response, indicating only that the target chemical is present in the specimen at a concentration greater than a specified threshold. A survey of 5 point-of-care immunoassay devices found that each had a false negative rate for opioids 1% and a false positive rate 0.25%. 31 Immunoassay tests provide fast and convenient drug detection but lack specificity for individual opioids. Many are sensitive for morphine or codeine but show limited cross-reactivity for semisynthetic opioids such as oxycodone or oxymorphone and will not detect synthetic opioids such as meperidine or fentanyl. 30,32,33 These tests may be applied for verifying compliance when patients are prescribed morphine and codeine, but they have limited use in screening for opioid abuse. Some point-of-care immunoassays are available that are specifically designed to detect semisynthetic (eg, oxycodone, buprenorphine) or synthetic (eg, fentanyl, propoxyphene, meperidine, methadone) opioids. 30 The conclusiveness of immunoassay findings and need for laboratory confirmation tests will depend on the opioid prescribed and the immunoassay tests performed. Careful selection of a panel of immunoassays to detect frequently abused drugs will often be sufficient to deter or detect abuse. However, the limitations of point-of-care immunoassay tests must be taken into consideration. For example, codeine and hydrocodone cannot be distinguished by point-of-care tests but can be readily differentiated by laboratory tests despite having closely related chemical structures and identical molecular weights. Similarly, oxycodone-sensitive immunoassay tests will not distinguish oxycodone from oxymorphone. In contrast, many of the immunoassays for synthetic opioids such as methadone are quite specific and generally provide reliable results. Because of the inherent risk of false positives with all immunoassays, questionable results should be verified by laboratory confirmation tests. Laboratory Tests A good laboratory can provide an invaluable service to those who wish to conduct and interpret urine drug tests. The laboratory should be accredited to state and federal requirements, use good laboratory practices, comply with analytical toxicology guidelines and standards, maintain rigorous procedures and documentation, and follow appropriate forensic protocols. Knowledgeable staff (eg, board-certified toxicologists) should be available to help select appropriate test panels, detection thresholds, and interpret results. Laboratory testing is more accurate than point-of-care testing and provides specific and quantitative information on what drugs and/or metabolites are present. When specimens arrive at a laboratory for drug testing, they are logged in and assigned unique identification codes to allow recording and tracking of each specimen throughout its existence and to report and store all test results associated with the specimen Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

4 Edward J. Cone and Yale H. Caplan for years. Laboratories typically employ immunoassay tests performed on high-volume clinical analyzers for initial testing. Such tests allow rapid separation of negative specimens from those that require confirmation testing for specific drugs and/or metabolites. Confirmation tests involve either liquid chromatography (LC) or gas chromatography (GC) in combination with mass spectrometry (MS) for detection and measurement of drugs and metabolites in biological specimens. Tandem mass spectrometry (MS/MS) is a more sensitive form of MS that consists of 2 MS systems positioned in series. The combination of LC or GC, for separation of specimens into component molecules, with MS systems, for identification and measurement of unique structural features, provides a laboratory with the ability to identify and measure drugs and/or metabolites in biological fluids at low concentrations. Laboratory testing should be performed as a confirmation test after ambiguous positive immunoassay results, but can also be used periodically (or randomly) as a first-line technique to detect drugs that may escape detection by immunoassays or be present at concentrations lower than the minimum threshold of available immunoassays. 33 Specimen Validity Tests Substance-abusing patients may be highly motivated to falsify or tamper with a urine test to avoid detection of abuse or diversion. Specimen validity tests are performed to ensure that the urine specimen has not been diluted, substituted, or adulterated to conceal drug abuse. 34,35 Dilution by drinking large amounts of fluid before producing the specimen or by adding a liquid to the specimen may be attempted to lower the concentration of any present drug below the test threshold. Substitution involves switching the specimen with another individual s urine or a fluid resembling urine. Adulteration is the addition of a chemical to the specimen that interferes with the testing process. 34,36,37 Ensuring specimen integrity begins during collection in the physician s office, with an inspection of the specimen s color, clarity, and foaming characteristics. Urine is typically yellow; a lack of yellow pigment might indicate dilution. Freshly voided urine should be clear, and foam on urine should be the same color as the rest of the specimen. 35 The temperature of urine should be taken and recorded within 4 minutes of specimen collection and should be between 90 F and 100 F. 35 Many collection cups contain a temperature strip that indicates if the specimen is at the correct temperature. Temperature is an effective validity test because it is difficult for patients to keep a substituted urine specimen at body temperature, even when techniques such as bringing the substitute specimen in a condom taped to the thigh are used. Specimens with temperatures out of range cannot be accepted as valid. Protocols for government-mandated testing, such as those for truck drivers 38 or nuclear facility workers, 39 mandate that a cold specimen must be replaced with a witnessed collection specimen. In the clinical setting, this further test needs to be discussed with the patient, unless a treatment agreement is already in place with consent to a witnessed collection follow-up of aberrant results. Failure to record the specimen temperature accurately within 4 minutes of micturition obviously thwarts the value of this test. Urine ph is typically between 4.5 and 8, although bacterial infection can result in a ph level 8, or even 9. ph can be assessed easily at the point of collection using a ph electrode, colorimetric test, or test strip. 40 Tests are also available to detect various adulterants such as glutaraldehyde, nitrite, chromate, and other oxidizing agents. Specimen dilution results in a low creatinine level and low specific gravity. 41 The most broadly used guidelines for identifying dilute and substituted specimens are those employed in the federal workplace program. 42 A dilute specimen is defined as containing creatinine in the range of 2 to 20 mg/dl. A substituted specimen is defined as containing creatinine 2 mg/dl and a specific gravity or Dilute urine can occur as a result of overhydration by water-loading or medical conditions. Thus, the occurrence of a dilute specimen may in some cases be suspicious but in others may be the expected result. The occurrence of a substituted specimen should be viewed as the equivalent of a failed drug test. Interpreting Urine Drug Test Results What Urine Tests Tell You Positive urine test results indicate that the prescribed opioid is present above a preselected threshold. A positive result for additional opioids must represent either the known metabolites of the prescribed compound, or the presence of licit or illicit opioids obtained from another source. Unexpected positive tests for nonopioid drugs, licit or illicit, require appropriate follow-up. Negative findings indicate that the target drug is not present in the sample but do not allow for determining the reason for its absence. Patients may not comply with prescribed therapies for clinical reasons, such as a reduced need for analgesia or adverse events. Noncompliance may also 94 Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

5 Urine Toxicology Testing in Chronic Pain Management represent drug diversion. Alternatively, the specimen may have been adulterated or substituted, or the physician may have ordered a test panel or threshold incapable of detecting therapeutic levels of the target drug. For prescribed opioids, negative findings will require appropriate follow-up with the patient. When screening for drugs of abuse, faith in negative urine test results depends on an assurance of sample validity. What Urine Tests Do Not Tell You Specialized immunoassay tests are generally required for detection of opioids other than morphine and codeine. 30,32,33,43,44 When positive immunoassay tests are reflexed to confirmation testing, the test panel will include only the drugs identified by the immunoassay. Confirmation tests provide quantitative values of absolute and relative concentrations of drugs and metabolites, but the dose taken and the time at which it was taken cannot be determined reliably. Many factors influence urine drug concentrations, including the timing of the dose, fluid intake, and individual differences in metabolism and excretion rates. Confirmation tests are helpful in detecting abuse and diversion, but will not detect patients who abuse their prescription by hoarding and binging, obtaining additional quantities of drugs illegally, or selling most of their medication but keeping some to take just before their urine test. Differentiating Which Opioid Was Taken Many opioids produce metabolites chemically identical to other prescription opioids (Table 1). Determining whether the patient is illicitly taking one of the metabolites of the prescribed opioid as a discrete drug can be challenging even for those experienced in test interpretation. Positive urine tests for opioids that are not metabolites of the prescribed opioid indicate abuse. Because the synthetic opioids oxycodone, fentanyl, and tramadol are not produced as metabolites of any other opioid, positive results for these drugs indicate that they were ingested. Conversely, morphine, oxymorphone, hydrocodone, and hydromorphone are produced as metabolites of other opioids, and the presence of one of these opioids in a urine specimen may not indicate abuse if (and only if) the prescribed opioid is known to produce one of them as a metabolite. The metabolism of one opioid to another commercial opioid affects the interpretation of urine test results, as illustrated in the following examples. Table 1. Opioid Metabolites Opioid Metabolites Identical to Pharmaceutical Opioids Metabolites That are Not Pharmaceuticals Morphine Hydromorphone (minor) Morphine-3-glucuronide Morphine-6-glucuronide Hydromorphone Dihydromorphine Hydromorphone-3-glucuronide Hydrocodone Hydromorphone Norhydrocodone Dihydrocodeine Codeine Morphine Norcodeine Hydrocodone (minor) Oxycodone Oxymorphone Noroxycodone Oxycodol Oxymorphone None Oxymorphone-3-glucuronide Oxymorphol Fentanyl None Norfentanyl Tramadol None O-desmethyl-tramadol Nortramadol Butorphanol None Hydroxybutorphanol Norbutorphanol Propoxyphene None Norpropoxyphene Methadone None 2-Ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine 2-Ethyl-5-methyl-3,3-diphenylpyrroline Buprenorphine None Norbuprenorphine Norbuprenorphine-3-glucuronide Buprenorphine-3-glucuronide Heroin Morphine Codeine (contaminant) 6-Monoacetylmorphine Reproduced with permission from Mayo Clin Proc. 111 Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

6 Edward J. Cone and Yale H. Caplan Morphine, Codeine, or Heroin The metabolism of codeine, morphine, and heroin is illustrated in Figure 1. Morphine produces only small quantities of hydromorphone as a metabolite. If a patient prescribed morphine tests positive for hydromorphone, confirmatory tests quantifying the relative levels of these drugs are needed to determine whether the hydromorphone was taken as a discrete entity Sometimes different opioids will produce a common metabolite. Both codeine and heroin produce morphine as a metabolite. When morphine and codeine are present in the urine of a patient prescribed codeine, quantitation of the relative levels is essential to determine whether the patient is taking codeine alone, codeine plus morphine, or heroin. If more morphine than codeine is present, the patient is likely taking heroin or morphine separately in addition to codeine. 48 Although heroin use is confirmed if either heroin or its 6-monoacetylmorphine (6-MAM) metabolite is identified, the short half-lives of heroin (3 5 min) and 6-MAM (25 30 min) limit their utility for confirming heroin use to a few hours. 49,50 Oxycodone and Oxymorphone Oxycodone is metabolized by cytochrome P450 (CYP) 3A4 to noroxycodone and by CYP2D6 to oxymorphone. 51 A patient prescribed oxycodone who tests positive for oxymorphone needs a quantitative analysis to confirm that the relative quantity of oxycodone is greater than oxymorphone. Only at late stages of excretion can the oxymorphone level exceed oxycodone. 33 Nonetheless, urine toxicology results cannot absolutely confirm that a patient took only his prescribed oxycodone and not some additional oxymorphone. Urine drug testing for patients prescribed oxymorphone is easy to interpret because oxymorphone does not produce any metabolites that can be mistaken for another prescribed opioid. Although oxymorphone tablets may contain up to 1% oxycodone as a manufacturing byproduct, this minute quantity of oxycodone should not be detectable on urine testing. Urine testing for oxymorphone via liquid chromatography coupled with MS/MS should reveal a single opioid ( 99% oxymorphone). 52 Figure 1. Metabolism of codeine, morphine, and heroin ,55 Codeine Heroin Hydrocodone Morphine 6-MAM If codeine to hydrocodone ratio < 10, codeine is not the sole source If codeine to morphine ratio < 6, codeine is likely not the sole source Source can only be heroin Hydromorphone Level generally lower than its hydrocodone source and below detection if only codeine was ingested Abbreviation: 6-MAM, 6-monoacetylmorphine. 96 Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

7 Urine Toxicology Testing in Chronic Pain Management Hydrocodone Hydrocodone is the most commonly prescribed opioid analgesic in the United States. 53 Hydrocodone is metabolized to dihydrocodeine and hydromorphone, 33,54 and codeine may produce hydrocodone as a minor metabolite. 55 Hydrocodone levels generally exceed hydromorphone levels except at late stages of excretion. 33 Although a patient prescribed codeine may have hydrocodone present in the urine at a concentration as high as 11% of the codeine, 55 this small quantity of hydrocodone is highly unlikely to produce a detectable level of hydromorphone, even though hydromorphone is the chief metabolite of hydrocodone. The presence of hydromorphone in a patient prescribed codeine suggests that hydromorphone was taken separately. Although codeine produces hydrocodone as a metabolite, hydrocodone does not produce codeine as a metabolite; hence, the presence of codeine in a patient prescribed hydrocodone indicates that the codeine was taken as a discrete entity. It is important to remember that, even if a patient is prescribed codeine, the presence of codeine and hydrocodone can mean that either codeine alone or both drugs were taken. The metabolism of codeine shows substantial interpatient variability, 56 meaning that the ratio of hydrocodone to codeine in urine provides limited information about whether the patient took codeine alone or both drugs. Similarly, in a patient prescribed hydrocodone, the presence of hydrocodone and hydromorphone can mean that either hydrocodone alone or both drugs were taken. Communication with patients about their urine test results 57 and behavioral monitoring 58 can augment the objective finding of urine tests to distinguish appropriate use from abuse. Nonopioid Drugs of Abuse Patients who abuse opioids may abuse other controlled substances (eg, marijuana, amphetamines, cocaine, benzodiazepines) to enhance or counter opioid effects or to serve as substitutes when a preferred opioid (eg, heroin) is not available The majority of emergency department visits in the United States for illicit drug use involve concurrent alcohol use. 19 It is not uncommon for alcoholism to be present in patients requiring opioids for serious conditions, 66 and a substantial percentage of opioid-related fatalities also test positive for alcohol Patients must be advised that opioids can be expected to have additive effects when used in conjunction with alcohol and that the product labeling for most opioids advises against concurrent alcohol consumption. 51,67 70 Benzodiazepines Immunoassays reliably identify most benzodiazepines, 71 with a few exceptions such as clonazepam. 72 False-positive immunoassay results may occur in patients treated with the nonsteroidal anti-inflammatory drugs fenoprofen, flurbiprofen, indomethacin, ketoprofen, or tolmetin. 73 Amphetamine/Methamphetamine Interpretation of positive immunoassay results for amphetamine and methamphetamine is problematic as a result of their structural similarity to a wide range of prescription and over-the-counter products, including ephedrine, 74 trazodone, 75 selegiline, 76 and bupropion. 77 Laboratory confirmation tests are necessary to identify a specific drug. Well-informed drug abusers may claim to have used an over-the-counter product to account for a positive immunoassay result, but stereospecific chromatography tests conducted by a laboratory can differentiate amphetamine and methamphetamine from the medications that resemble them. 78,79 Cocaine Immunoassays are sensitive for cocaine and its principal metabolites, benzoylecgonine and ecgonine methylester, showing little cross-reactivity for other compounds. Although cocaine is a legal schedule II drug approved for use as a topical anesthetic, it is so very rarely used in clinical practice that a positive finding for cocaine should essentially always be interpreted as suggesting abuse. Marijuana Marijuana is easily detected by immunoassay. Contrary to popular myth, passive exposure to marijuana smoke does not explain positive urine test results. 80,81 However, delta-9-tetrahydrocannabinol (THC) is approved in the United States for the treatment of nausea in cancer patients undergoing chemotherapy, and as an appetite stimulant in AIDS patients (Marinol ). Thus, a positive immunoassay for THC may not indicate abuse. Moreover, the antiretroviral efavirenz 82 or the proton pump inhibitor pantoprazole 83 can produce false-positive immunoassay results. False-positive results for marijuana have also been reported following ingestion of foods containing hemp seed oil, but this is considered highly unlikely Confirmation testing for marijuana metabolites may be required to rule out falsepositive immunoassays. Alcohol Alcohol typically remains in the body for 12 hours, making use of blood tests or the standard hand-held breath devices (breathalyzers) necessary, but often impractical, for effective alcohol monitoring. However, the minor alcohol metabolite Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

8 Edward J. Cone and Yale H. Caplan ethyl glucuronide remains in urine for several days 88,89 and can be tested using recently developed tests. 90,91 These tests are highly sensitive but may produce false-positive results in patients with incidental exposure to alcohol in cough medicines, mouthwashes, certain foods, communion wine, or even nonalcoholic beer. For this reason, the appropriate threshold for ethyl glucuronide is still not clear. 92 Red-Flag Findings Signs of Specimen Tampering Specimen tampering (cold samples; diluted, adulterated, or substituted samples) is a clear indication of abuse and necessitates confirmatory testing using witnessed specimen collection. 35 The Prescribed Opioid or its Metabolites are Absent from the Urine Specimen Absence of the prescribed opioid or its metabolites in the urine may indicate drug diversion or trafficking. It also may indicate that the patient is using his or her medications intermittently or only for severe episodes or that the patient experienced increased pain and consumed his or her supply earlier than anticipated. It may indicate that the patient is an ultra-fast metabolizer or has induced enzyme levels and clears the drug too rapidly to allow detection. For example, coadministration of antiretrovirals, which are CYP3A4 inducers, can decrease methadone levels, leading to withdrawal symptoms. 93 Absence of the prescribed opioid may indicate that an inappropriate test was performed. As stated previously, immunoassays may not detect synthetic or semisynthetic opioids, and immunoassays designed for abuse screening may have thresholds set too high to detect therapeutic levels. When ordering confirmation tests, instructions to the laboratory may not have included the prescribed drug or a request for appropriate detection thresholds. The Prescribed Opioid and its Metabolites are Identifi ed in Suspicious Relative Proportions Presence of the prescribed opioid does not exclude the possibility of abuse. Because urine testing cannot determine the dose taken, it cannot exclude the possibility that a patient who is prescribed an opioid is taking additional unprescribed quantities of the same opioid. As discussed previously, morphine, codeine, hydromorphone, hydrocodone, and oxymorphone can be present as metabolites of other opioids, and disproportionate metabolite levels can indicate that the prescribed opioid is not the only source. Urine test results must be considered in the context of the overall clinical picture, including history of abuse, positive findings for other drugs, and drug-seeking behaviors. Unprescribed Opioids, Unprescribed Licit Drugs, Illicit Drugs, or Alcohol are Detected Positive immunoassay tests for unprescribed licit drugs or illicit drugs require confirmation testing. Although guidelines state that a history of abuse or addiction does not preclude access to effective pain therapy, 94 concurrent abuse of drugs or alcohol presents an unacceptable risk of potentially lethal interactions with opioid pain therapy. Procedural Considerations in Urine Drug Testing Establish a Treatment Agreement at the Outset of Therapy Recommendations for conducting urine drug testing in patients receiving opioids for chronic pain are summarized in Table 2. When initiating opioid therapy, a signed treatment agreement between physicians and opioid-treated patients is helpful for setting expectations and boundaries, 95 making it easier to identify and intervene if signs of misuse are present. Drug testing should be a condition of opioid therapy in any treatment agreement with patients and should include opioids, other licit and illicit drugs, and drugs of abuse. A patient who is unwilling to undergo drug testing should not be prescribed opioids, and unwillingness in a patient who had previously consented to testing is a red flag for abuse or diversion. Treatment agreements should stipulate that testing will be random if there are no signs of abuse or diversion or unless patient function does not permit it, but more frequent testing will be needed when abuse or diversion is suspected. Agreements should also specify that evidence suggestive of sample tampering would necessitate follow-up with witnessed specimen collection. Finally, it should be agreed that testing would be at frequent regular intervals after any change in therapy or in selected patients receiving multiple medications. Assess Patients for Psychiatric Comorbidity and Addiction History or Risk All patients should be evaluated for previous abuse or addiction history as well as psychiatric comorbidities (eg, personality disorders, depression, anxiety, major mental illness) that may predispose to substance abuse Screening questionnaires such as the Opioid Risk Tool, 99 Current Opioid Misuse Measure, 100 or the revised Screener and Opioid Assessment for Patients with Pain 101 may be of value for identifying patients with increased risk of abuse. Screening tools and urine drug testing should be discussed with patients to assure them that monitoring does not indicate a lack 98 Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

9 Urine Toxicology Testing in Chronic Pain Management Table 2. Recommendations for Urine Toxicology Testing Employ urine testing as part of a universal precaution approach to risk management Assess patients for psychiatric comorbidity or history of abuse/addiction before starting treatment Obtain informed consent from the patient Enter into a signed treatment agreement with the patient Urine testing should be A condition of opioid therapy Inclusive of other common drugs of abuse Random if there are no signs of abuse or diversion More frequent if abuse or diversion is suspected More frequent after changes in therapy More frequent in patients receiving multiple medications Evaluate patient pain and function before and during opioid therapy Monitor patient behavior, adverse events, and affect during treatment To prevent specimen dilution, substitution, or adulteration, implement a procedure for measuring Specimen appearance Temperature ph Creatinine levels Specifi c gravity Adulterants Follow-up aberrant results (ie, unexpected positive or negative results) Conduct confi rmatory tests Communicate with the patient Consider interruption or discontinuation of opioid therapy If necessary, refer patient to addiction specialist or treatment facility of trust but rather is a universal precaution taken with all patients treated with opioids. Thorough patient assessment is also an opportunity to direct patients exhibiting abuse to appropriate interventions. Evaluate Preintervention and Postintervention Pain and Function Pain is subjective, making it difficult to determine whether a patient s complaints are legitimate or a pretense. Careful evaluation of medical history and objective tests of function can support or undermine the veracity of a patient s expressed pain level. Physicians must help patients maintain realistic expectations about potential benefits and risks of treatment. Patients with unrealistic expectations about the benefits of treatment (eg, accepting reduction vs absence of pain) may engage in drug seeking, unrelated to addiction or abuse, in an effort to obtain a level of relief that may not be possible given their medical condition. Physicians should regularly assess adverse effects, aberrant behavior, and patient affect. 102,103 Aberrant behaviors include reports of lost or stolen medication, consumption in excess of the prescribed dosage, unscheduled visits or frequent phone calls to the physician s office, and claims of multiple drug intolerances requiring medication change. The last behavior allows for recreational use or diversion of the opioid that has been replaced. Altered affect can be a sign of abuse or that the opioid has unwanted effects, requiring the patient to be switched to another drug. 104 A request to switch opioids can suggest either abuse or a legitimate clinical need. Physicians need to consider the patient s overall clinical profile to distinguish these possibilities. Managing patient expectations in relation to treatment risks begins with clear definitions of tolerance, dependence, and addiction. Tolerance necessitating dosage escalation is a natural occurrence with ongoing therapy, and opioid withdrawal symptoms are expected after abrupt discontinuation or dose reduction. These processes should not be confused with addiction, which has been defined as a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. 104 Carefully Document All Results Urine drug testing procedures and results should be carefully documented. This is important not only medicolegally, but also to avoid misunderstanding between the physician and patient. When patients are compliant, documentation can reinforce positive behaviors. Implement a Protocol to Follow-up Aberrant Results Follow-up of any suspicious positive or negative urine test result should include confirmatory tests and frank communication between the physician and patient. Laboratories can help select appropriate tests to confirm suspicious but inconclusive findings. Although patient self-reports of drug use can be unreliable, one study found that self-report agreed with urine drug test results in 90% of cases when the interview was conducted after the drug test was administered. 57 This study highlights the way in which urine drug testing can foster good communication between physicians and patients because patients are more likely to be forthcoming when the physician presents them with concrete evidence of aberrant drug use. Although addiction is defined as a disease, physicians must bear in mind that the effective treatment of this disease requires the physician to set and uphold strict boundaries and limits and also requires the patient to accept the consequences of his or her actions. Confrontation of a substance abusing patient in a supportive, motivational context can be an effective first step to recovery Moreover, physicians must consider the safety, ethics, and legality of continuing to prescribe opioids in the face of evidence of abuse or diversion. Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

10 Edward J. Cone and Yale H. Caplan Conclusion Although opioid therapy is accompanied by a risk of addiction or abuse, a number of researchers have concluded that the risk of addiction in patients with chronic pain does not differ significantly from that of the general population. Moreover, patients with a history of substance abuse may be eligible for pain management with opioid medications if monitored closely. 108,109 The APS and AAPM maintain that a history of addiction should not prohibit the judicious use of opioids in patients with chronic noncancer pain who are not responsive to other treatments. 110 In any opioid-treated patient, urine drug testing can help ensure compliance, deter diversion, and detect abuse of prescribed opioids and other drugs, thereby preventing harm to the patient, the prescriber, and society. Urine drug testing can help guide physician treatment decisions, improve communication, and build trust between physician and patient, especially for patients at higher risk of abuse who nonetheless have compelling indications for strong pain relief. Acknowledgments The authors have received no direct or indirect commercial financial incentive associated with publishing this article. Jeffrey Coleman, MA, of Complete Healthcare Communications, Inc., provided research and editorial assistance for the development of the submitted manuscript, with support from Endo Pharmaceuticals, Inc. Conflict of Interest Statement Edward J. Cone, PhD, and Yale H. Caplan, PhD disclose conflicts of interest with Aegis Sciences Corp. References 1. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100(6): World Health Organization. Cancer Pain Relief. 2nd ed. Geneva, Switzerland: WHO Office of Publication; American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. 5th ed. Glenview, IL: American Pain Society; Practice guidelines for cancer pain management. A report by the American Society of Anesthesiologists Task Force on Pain Management, Cancer Pain Section. Anesthesiology. 1996;84(5): AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(6 suppl):s205 S Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7): American Pain Society. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis. Chicago, IL: American Pain Society; Bhamb B, Brown D, Hariharan J, Anderson J, Balousek S, Fleming MF. Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin. 2006;22(9): Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6): Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2): Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of selfreported drug use in chronic pain patients. Clin J Pain. 1999;15(3): Preston KL, Silverman K, Schuster CR, Cone EJ. Comparison of self-reported drug use with quantitative and qualitative urinalysis for assessment of drug use in treatment studies. NIDA Res Monogr. 1997;167: Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4): Yang JM. Toxicology and drugs of abuse testing at the point of care. Clin Lab Med. 2001;21(2): Reisfield GM, Bertholf R, Barkin RL, Webb F, Wilson G. Urine drug test interpretation: what do physicians know? J Opioid Manag. 2007;3(2): Reisfield GM, Webb FJ, Bertholf RL, Sloan PA, Wilson GR. Family physicians proficiency in urine drug test interpretation. J Opioid Manag. 2007;3(6): Hardt J, Jacobsen C, Goldberg J, Nickel R, Buchwald D. Prevalence of chronic pain in a representative sample in the United States. Pain Med. 2008;9(7): National Pain Survey: Executive Summary. Ortho-McNeil Pharmaceutical. Pain_Survey.html. Accessed June 2, SAMHSA. Results from the 2002 National Survey on Drug Use and Health: National Findings, DHHS Publication No. SMA Rockville, MD: Department of Health and Human Services; Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drugrelated behaviors? A structured evidence-based review. Pain Med. 2008;9(4): Manchikanti L, Manchukonda R, Pampati V, et al. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Pain Physician. 2006;9(2): Manchikanti L, Fellows B, Damron KS, Pampati V, McManus CD. Prevalence of illicit drug use among individuals with chronic pain in the Commonwealth of Kentucky: an evaluation of patterns and trends. J Ky Med Assoc. 2005;103(2): Manchikanti L, Manchukonda R, Damron KS, Brandon D, McManus CD, Cash K. Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician. 2006;9(1): Manchikanti L, Pampati V, Damron KS, Fellows B, Barnhill RC, Beyer CD. Prevalence of opioid abuse in interventional pain medicine practice settings: a randomized clinical evaluation. Pain Physician. 2001;4(4): Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

11 Urine Toxicology Testing in Chronic Pain Management 25. Manchikanti L, Pampati V, Damron KS, Beyer CD, Barnhill RC, Fellows B. Prevalence of prescription drug abuse and dependency in patients with chronic pain in western Kentucky. J Ky Med Assoc. 2003;101(11): Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain. 2008;24(6): Hammett-Stabler CA, Pesce AJ, Cannon DJ. Urine drug screening in the medical setting. Clin Chim Acta. 2002;315(1 2): Bush DM. The U.S. Mandatory Guidelines for Federal Workplace Drug Testing Programs: current status and future considerations. Forensic Sci Int. 2008;174(2 3): Vandevenne M, Vandenbussche H, Verstraete A. Detection time of drugs of abuse in urine. Acta Clin Belg. 2000;55(6): Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37(4): Crouch DJ, Hersch RK, Cook RF, Frank JF, Walsh JM. A field evaluation of five on-site drug-testing devices. J Anal Toxicol. 2002;26(7): Cone EJ, Dickerson S, Paul BD, Mitchell JM. Forensic drug testing for opiates. IV. Analytical sensitivity, specificity, and accuracy of commercial urine opiate immunoassays. J Anal Toxicol. 1992; 16(2): Smith ML, Hughes RO, Levine B, Dickerson S, Darwin WD, Cone EJ. Forensic drug testing for opiates. VI. Urine testing for hydromorphone, hydrocodone, oxymorphone, and oxycodone with commercial opiate immunoassays and gas chromatography-mass spectrometry. J Anal Toxicol. 1995;19(1): Caplan YH. Specimen validity testing. In: Karch SB, ed. Drug Abuse Handbook. Boca Raton, FL: CRC Press; 2007: Cook JD, Caplan YH, LoDico CP, Bush DM. The characterization of human urine for specimen validity determination in workplace drug testing: a review. J Anal Toxicol. 2000;24(7): Cody JT, Valtier S, Kuhlman J. Analysis of morphine and codeine in samples adulterated with Stealth. J Anal Toxicol. 2001;25(7): Wu AH, Bristol B, Sexton K, Cassella-McLane G, Holtman V, Hill DW. Adulteration of urine by Urine Luck. Clin Chem. 1999;45(7): US Department of Transportation. Urine Specimen Collection Guidelines. US Department of Transportation; US Nuclear Regulatory Commission. Checking the acceptability of the urine specimen. US Nuclear Regulatory Commission; Cook JD, Strauss KA, Caplan YH, Lodico CP, Bush DM. Urine ph: the effects of time and temperature after collection. J Anal Toxicol. 2007;31(8): Fraser AD, Zamecnik J. Impact of lowering the screening and confirmation cutoff values for urine drug testing based on dilution indicators. Ther Drug Monit. 2003;25(6): Department of Health and Human Services. Mandatory guidelines for federal workplace drug testing programs; notice. Federal Registry. 2008;73: Luzzi VI, Saunders AN, Koenig JW, et al. Analytic performance of immunoassays for drugs of abuse below established cutoff values. Clin Chem. 2004;50(4): Smith ML, Shimomura ET, Summers J, et al. Detection times and analytical performance of commercial urine opiate immunoassays following heroin administration. J Anal Toxicol. 2000;24(7): McDonough PC, Levine B, Vorce S, Jufer RA, Fowler D. The detection of hydromorphone in urine specimens with high morphine concentrations. J Forensic Sci. 2008;53(3): Cone EJ, Caplan YH, Moser F, Robert T, Black D. Evidence that morphine is metabolized to hydromorphone but not to oxymorphone. J Anal Toxicol. 2008;32(4): Cone EJ, Heit HA, Caplan YH, Gourlay D. Evidence of morphine metabolism to hydromorphone in pain patients chronically treated with morphine. J Anal Toxicol. 2006;30(1): Kirchheiner J, Schmidt H, Tzvetkov M. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4): Cone EJ, Jufer R, Darwin WD, Needleman SB. Forensic drug testing for opiates. VII. Urinary excretion profile of intranasal (snorted) heroin. J Anal Toxicol. 1996;20(6): Inturrisi CE, Max MB, Foley KM, Schultz M, Shin SU, Houde RW. The pharmacokinetics of heroin in patients with chronic pain. N Engl J Med. 1984;310(19): OxyContin [package insert]. Stamford, CT: Purdue Pharma LP; Sloan PA, Barkin RL. Oxymorphone and oxymorphone extended release: a pharmacotherapeutic review. J Opioid Manag. 2008;4(3): Manchikanti L. National drug control policy and prescription drug abuse: facts and fallacies. Pain Physician. 2007;10(3): Hydrocodone [package insert]. Corona, CA: Watson Laboratories; Oyler JM, Cone EJ, Joseph RE Jr, Huestis MA. Identification of hydrocodone in human urine following controlled codeine administration. J Anal Toxicol. 2000;24(7): Yue QY, Alm C, Svensson JO, Saäe J. Quantification of the O- and N-demethylated and the glucuronidated metabolites of codeine relative to the debrisoquine metabolic ratio in urine in ultrarapid, rapid, and poor debrisoquine hydroxylators. Ther Drug Monit. 1997;19(5): Hamid R, Deren S, Beardsley M, Tortu S. Agreement between urinalysis and self-reported drug use. Subst Use Misuse. 1999;34(11): Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002;18(4 suppl):s76 S Cone EJ, Fant RV, Rohay JM, et al. Oxycodone involvement in drug abuse deaths. II. Evidence for toxic multiple drug-drug interactions. J Anal Toxicol. 2004;28(7): Cone EJ, Fant RV, Rohay JM, et al. Oxycodone involvement in drug abuse deaths: a DAWN-based classification scheme applied to an oxycodone postmortem database containing over 1000 cases. J Anal Toxicol. 2003;27(2): Denton JS, Donoghue ER, McReynolds J, Kalelkar MB. An epidemic of illicit fentanyl deaths in Cook County, Illinois: September 2005 through April J Forensic Sci. 2008;53(2): Hull MJ, Juhascik M, Mazur F, Flomenbaum MA, Behonick GS. Fatalities associated with fentanyl and co-administered cocaine or opiates. J Forensic Sci. 2007;52(6): Shields LB, Hunsaker Iii JC, Corey TS, Ward MK, Stewart D. Methadone toxicity fatalities: a review of medical examiner cases in a large metropolitan area. J Forensic Sci. 2007;52(6): Wolf BC, Lavezzi WA, Sullivan LM, Flannagan LM. Methadone-related deaths in Palm Beach County. J Forensic Sci. 2004;49(2): Manchikanti L, Damron KS, McManus CD, Barnhill RC. Patterns of illicit drug use and opioid abuse in patients with chronic pain at initial evaluation: a prospective, observational study. Pain Physician. 2004;7(4): Parsons HA, Delgado-Guay MO, El Osta B, et al. Alcoholism screening in patients with advanced cancer: impact on symptom burden and opioid use. J Palliat Med. 2008;11(7): Kadian [package insert]. Piscataway, NJ: Alpharma, OPANA ER [package insert]. Chadds Ford, PA: Endo Pharmaceuticals, Inc.; Duragesic [package insert]. Titusville, NJ: Janssen Pharmaceuticals, Inc.; Dilaudid-HP [package insert]. Chicago, IL: Abbott Laboratories; DeRienz RT, Holler JM, Manos ME, Jemionek J, Past MR. Evaluation of four immunoassay screening kits for the detection of benzodiazepines in urine. J Anal Toxicol. 2008;32(6): Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

12 Edward J. Cone and Yale H. Caplan 72. Elian AA. ELISA detection of clonazepam and 7-aminoclonazepam in whole blood and urine. Forensic Sci Int. 2003;134(1): Joseph R, Dickerson S, Willis R, Frankenfield D, Cone EJ, Smith DR. Interference by nonsteroidal anti-inflammatory drugs in EMIT and TDx assays for drugs of abuse. J Anal Toxicol. 1995;19(1): Stout PR, Klette KL, Horn CK. Evaluation of ephedrine, pseudoephedrine and phenylpropanolamine concentrations in human urine samples and a comparison of the specificity of DRI amphetamines and Abuscreen online (KIMS) amphetamines screening immunoassays. J Forensic Sci. 2004;49(1): Roberge RJ, Luellen JR, Reed S. False-positive amphetamine screen following a trazodone overdose. J Toxicol Clin Toxicol. 2001;39(2): Maurer HH, Kraemer T. Toxicological detection of selegiline and its metabolites in urine using fluorescence polarization immunoassay (FPIA) and gas chromatography-mass spectrometry (GC-MS) and differentiation by enantioselective GC-MS of the intake of selegiline from abuse of methamphetamine or amphetamine. Arch Toxicol. 1992;66(9): Weintraub D, Linder MW. Amphetamine positive toxicology screen secondary to bupropion. Depress Anxiety. 2000;12(1): Nagai T, Matsushima K, Nagai T, et al. Interpretation and enantiomer analysis of methamphetamine abusers urine and illegally brewed methamphetamine crystals. J Anal Toxicol. 2000;24(2): Al-Dirbashi O, Wada M, Kuroda N, Inuduka S, Nakashima K. Enantiomer-specific high-performance liquid chromatography with fluorescence detection of methamphetamines in abusers hair and urine. Biomed Chromatogr. 1999;13(8): Cone EJ, Johnson RE, Darwin WD, et al. Passive inhalation of marijuana smoke: urinalysis and room air levels of delta-9-tetrahydrocannabinol. J Anal Toxicol. 1987;11(3): Niedbala S, Kardos K, Salamone S, Fritch D, Bronsqeest M, Cone EJ. Passive cannabis smoke exposure and oral fluid testing. J Anal Toxicol. 2004;28(7): SUSTIVA [package insert]. Princeton, NJ: Bristol-Myers Squibb; PROTONIX [package insert]. Philadelphia, PA: Wyeth Pharmaceu ticals; Fortner N, Fogerson R, Lindman D, Iversen T, Armbruster D. Marijuana-positive urine test results from consumption of hemp seeds in food products. J Anal Toxicol. 1997;21(6): Struempler RE, Nelson G, Urry FM. A positive cannabinoids workplace drug test following the ingestion of commercially available hemp seed oil. J Anal Toxicol. 1997;21(4): Bosy TZ, Cole KA. Consumption and quantitation of delta9- tetrahydrocannabinol in commercially available hemp seed oil products. J Anal Toxicol. 2000;24(7): Gustafson RA, Levine B, Stout PR, et al. Urinary cannabinoid detection times after controlled oral administration of delta9-tetrahydrocannabinol to humans. Clin Chem. 2003;49(7): Bergström J, Helander A, Jones AW. Ethyl glucuronide concentrations in two successive urinary voids from drinking drivers: relationship to creatinine content and blood and urine ethanol concentrations. Forensic Sci Int. 2003;133(1 2): Wurst FM, Skipper GE, Weinmann W. Ethyl glucuronide the direct ethanol metabolite on the threshold from science to routine use. Addiction. 2003;98(suppl 2): Beck O, Stephanson N, Böttcher M, Dahmen N, Fehr C, Helander A. Biomarkers to disclose recent intake of alcohol: potential of 5-hydroxytryptophol glucuronide testing using new direct UPLCtandem MS and ELISA methods. Alcohol Alcohol. 2007;42(4): Böttcher M, Beck O, Helander A. Evaluation of a new immunoassay for urinary ethyl glucuronide testing. Alcohol Alcohol. 2008;43(1): U.S. Department of Health and Human Services, Center for Substance Abuse Treatment. The Role of Biomarkers in the Treatment of Alcohol Use Disorders; Ferrari A, Coccia CP, Bertolini A, Sternieri E. Methadone metabolism, pharmacokinetics and interactions. Pharmacol Res. 2004;50(6): The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13(1): Hariharan J, Lamb GC, Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. J Gen Intern Med. 2007;22(4): Edlund MJ, Steffick D, Hudson T, Harris KM, Sullivan M. Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain. 2007;129(3): Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2): Wasan AD, Butler SF, Budman SH, Benoit C, Fernandez K, Jamison RN. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain. 2007;23(4): Webster LR, Webster RM. Predicting aberrant behaviors in opioidtreated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6): Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130(1 2): Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4): Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2): Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther. 2000;17(2): American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions Related to the Use of Opioids for the Treatment of Pain. A consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. Glenview, IL: Weaver MF, Jarvis MA, Schnoll SH. Role of the primary care physician in problems of substance abuse. Arch Intern Med. 1999;159(9): Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician. 1999;60(4): Polcin DL. Rethinking confrontation in alcohol and drug treatment: consideration of the clinical context. Subst Use Misuse. 2003;38(2): Heit HA. The truth about pain management: the difference between a pain patient and an addicted patient. Eur J Pain. 2001;5(suppl A): Weaver M, Schnoll S. Abuse liability in opioid therapy for pain treatment in patients with an addiction history. Clin J Pain. 2002; 18(4 suppl):s61 S The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13(1): Smith HS. Opioid metabolism. Mayo Clin Proc. 2009;84(7): Postgraduate Medicine, Volume 121, Issue 4, July 2009, ISSN , e-issn

EDUCATIONAL COMMENTARY METHADONE

EDUCATIONAL COMMENTARY METHADONE EDUCATIONAL COMMENTARY METHADONE Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE CME/CMLE credits see the Continuing Education

More information

Urine Drug Testing PracticeNotes Clinical Guide

Urine Drug Testing PracticeNotes Clinical Guide PracticeNotes Clinical Guide This PracticeNotes Clinical Guide offers a quick overview of the essentials of a patient-centered approach to urine drug testing (UDT), which remains an important tool for

More information

Analysis and interpretation of drug testing results from patients on chronic pain therapy: a clinical laboratory perspective

Analysis and interpretation of drug testing results from patients on chronic pain therapy: a clinical laboratory perspective Article in press - uncorrected proof Clin Chem Lab Med 2009;47(8):971 976 2009 by Walter de Gruyter Berlin New York. DOI 10.1515/CCLM.2009.220 2009/180 Analysis and interpretation of drug testing results

More information

Urine Drug Testing Methods 3-5

Urine Drug Testing Methods 3-5 Urine Drug Testing Methods 3-5 Type of Test Logistics Pearls Initial Screening Test: Immunoassay Confirmatory Test: Gas chromatography-mass spectrometry (GCMS) + or Liquid chromatography-mass spectrometry

More information

3/8/2018. Reasons for Doing UDT. UDT: A Tool in Risk Assessment. Faculty/Presenter Disclosure. Urine Drug Testing in Chronic Pain Management

3/8/2018. Reasons for Doing UDT. UDT: A Tool in Risk Assessment. Faculty/Presenter Disclosure. Urine Drug Testing in Chronic Pain Management Urine Drug Testing in Chronic Pain Management March 8, 2018 Faculty/Presenter Disclosure Faculty: Andrew J Smith, MDCM Relationships with commercial interests: None to report Andrew J Smith, MDCM Staff

More information

Urine Testing for Opioids

Urine Testing for Opioids Urine Testing for Opioids J. David Haddox, DDS, MD Vice President Risk Management & Health Policy Purdue Pharma L.P. Tufts Health Care Institute Program on Opioid Risk Management The Role of Urine Drug

More information

Testing for Controlled Substances

Testing for Controlled Substances Testing for illicit drugs Testing for Controlled Substances 1 Purposes: Employment Sports Screening medical eval. Legal Monitoring Treatment Probation Prescribing controlled substances Forensics 2 Drug

More information

URINE DRUG TOXICOLOGY

URINE DRUG TOXICOLOGY Psychiatry and Addictions Case Conference UW Medicine Psychiatry and Behavioral Sciences URINE DRUG TOXICOLOGY Suzanne E. Rapp, MD GENERAL DISCLOSURES The University of Washington School of Medicine also

More information

Patient-Centered Urine Drug Testing. Douglas Gourlay, MD, MSc, FRCPC, FASAM

Patient-Centered Urine Drug Testing. Douglas Gourlay, MD, MSc, FRCPC, FASAM Patient-Centered Urine Drug Testing Douglas Gourlay, MD, MSc, FRCPC, FASAM Declaration of Potential Conflict of Interest The content of this presentation is non- commercial and does not represent any conflict

More information

Urine drug testing it s not always crystal clear

Urine drug testing it s not always crystal clear Urine drug testing it s not always crystal clear Kirk Moberg, MD, PhD, FASAM Executive Medical Director, UnityPoint Health Illinois Institute for Addiction Recovery Clinical Professor of Internal Medicine

More information

How Can a Methadone and an Opiate-Positive Immunoassay Result be Reconciled in a Patient Prescribed only OxyContin and Wellbutrin?

How Can a Methadone and an Opiate-Positive Immunoassay Result be Reconciled in a Patient Prescribed only OxyContin and Wellbutrin? 190 Available online at www.annclinlabsci.org How Can a Methadone and an Opiate-Positive Immunoassay Result be Reconciled in a Patient Prescribed only OxyContin and Wellbutrin? Jude M. Abadie Department

More information

EDUCATIONAL COMMENTARY rd TEST EVENT Chemistry Urine Drug Testing

EDUCATIONAL COMMENTARY rd TEST EVENT Chemistry Urine Drug Testing EDUCATIONAL COMMENTARY 2003 3 rd TEST EVENT Chemistry Urine Drug Testing Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE

More information

The Drug Testing Process. Employer or Practice

The Drug Testing Process. Employer or Practice Disclosures Clinical Professor, Jefferson Medical College BOD MROCC [Medical Review Officer Certification Council] BOD National Sleep Foundation BOD POEMS [Pennsylvania Occupational & Environmental Medicine

More information

Trust but verify is good advice

Trust but verify is good advice PRINTER-FRIENDLY VERSION Available AT PainMedicineNews.com The Role of Urine Drug Monitoring in Pain Management Lynn R. Webster, MD Medical Director CRILifetree Research Salt Lake City, Utah President

More information

Cutoff levels for hydrocodone in a blood test

Cutoff levels for hydrocodone in a blood test Cutoff levels for hydrocodone in a blood test The premier DNA and drug testing company in the North Texas area. Specializing in legal cases but also provide testing for employers and private individuals.

More information

PROFESSIONALISM AND COMMENTARY. Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management

PROFESSIONALISM AND COMMENTARY. Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management bs_bs_banner Pain Medicine 2013; 14: 1813 1820 Wiley Periodicals, Inc. PROFESSIONALISM AND COMMENTARY Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management Disclosure: The

More information

Urine Drug Testing to Monitor Opioid Use In Managing Chronic Pain

Urine Drug Testing to Monitor Opioid Use In Managing Chronic Pain Faculty Disclosure Henry C. Nipper, PhD, DABCC Dr. Nipper has listed no financial interest/arrangement that would be considered a conflict of interest. Urine Drug Testing to Monitor Opioid Use In Managing

More information

Gold Standard for Urine Drug Testin Urine Drug Testing Why U rine? Urine?

Gold Standard for Urine Drug Testin Urine Drug Testing Why U rine? Urine? Gold Standard for Urine Drug Testing Developed by TRMC Pain Management Center Jill Duffy, RN,BC Pam Kennell, RN, BC Heidi Beisch, RN Urine Drug Testing A DIAGNOSTIC tool For an OBJECTIVE test Based on

More information

Illicit Drug Use Correlates with Negative Urine Drug Test Results for Prescribed Hydrocodone, Oxycodone, and Morphine

Illicit Drug Use Correlates with Negative Urine Drug Test Results for Prescribed Hydrocodone, Oxycodone, and Morphine Pain Physician 2012; 15:E687-E692 ISSN 2150-1149 Retrospective Evaluation Illicit Drug Use Correlates with Negative Urine Drug Test Results for Prescribed Hydrocodone, Oxycodone, and Morphine Amadeo Pesce,

More information

Controlled Substance Monitoring in the Age of the Opioid Epidemic

Controlled Substance Monitoring in the Age of the Opioid Epidemic Controlled Substance Monitoring in the Age of the Opioid Epidemic Paul E. Hilliard, MS, MD Hospital Pain Committee Chair Department of Anesthesiology CME housekeeping I have no financial disclosures AKA,

More information

Pain Medication Management Program Monitors Patient Compliance

Pain Medication Management Program Monitors Patient Compliance PeaceHealth Laboratories UPDATE 2014/15 Edition Pain Medication Management Program Monitors Patient Compliance BENEFITS Monitors analgesic medication adherence to ensure patient safety and protect your

More information

Using Liquid Chromatography Tandem Mass Spectrometry Urine Drug Testing to Identify Licit and Illicit Drug-Use in a Community-based Patient Population

Using Liquid Chromatography Tandem Mass Spectrometry Urine Drug Testing to Identify Licit and Illicit Drug-Use in a Community-based Patient Population Using Liquid Chromatography Tandem Mass Spectrometry Urine Drug Testing to Identify Licit and Illicit Drug-Use in a Community-based Patient Population Adam S. Ptolemy 1, Colleen Murray 2, Edward Dunn 3,

More information

Pain Medication Management Program Supports Patient Outcomes and Adherence

Pain Medication Management Program Supports Patient Outcomes and Adherence PeaceHealth Laboratories UPDATE 2015 Revised Edition Pain Medication Management Program Supports Patient Outcomes and Adherence BENEFITS Monitors analgesic medication adherence to ensure patient safety

More information

Clinical Policy: Outpatient Testing for Drugs of Abuse Reference Number: PA.CP.MP.50

Clinical Policy: Outpatient Testing for Drugs of Abuse Reference Number: PA.CP.MP.50 Clinical Policy: Reference Number: PA.CP.MP.50 Effective Date: 01/18 Last Review Date: 09/17 Coding Implications Revision Log Description Urine drug testing is a key diagnostic and therapeutic tool that

More information

Effective Date: Approved by: Laboratory Executive Director, Ed Hughes (electronic signature)

Effective Date: Approved by: Laboratory Executive Director, Ed Hughes (electronic signature) 1 Policy #: 803 (PLH-803-02) Effective Date: NA Reviewed Date: 4/11/2008 Subject: URINE DRUG SCREENS Approved by: Laboratory Executive Director, Ed Hughes (electronic signature) Approved by: Laboratory

More information

Medical Affairs Policy

Medical Affairs Policy Medical Affairs Policy Service: Urine Drug/Alcohol Screening and Testing PUM 250-0013-1803 Medical Policy Committee Approval 03/06/18 Effective Date 07/01/18 Prior Authorization Needed No Disclaimer: This

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy Drug Testing in Pain Management and Substance Abuse Treatment File Name: Origination: Last CAP Review: Next CAP Review: Last Review: drug_testing_in_pain_management_and_substance_abuse_treatment

More information

Laboratory Testing to Support Pain Management: Methods, Concepts and Case Studies

Laboratory Testing to Support Pain Management: Methods, Concepts and Case Studies Laboratory Testing to Support Pain Management: Methods, Concepts and Case Studies Frederick G. Strathmann, PhD, DABCC, (CC,TC) Medical Director, Toxicology Associate Scientific Director of MS ARUP Laboratories

More information

Urine Drug Testing. Methadone/Buprenorphine 101 Workshop. Ron Joe, MD, DABAM December 10, 2016

Urine Drug Testing. Methadone/Buprenorphine 101 Workshop. Ron Joe, MD, DABAM December 10, 2016 Urine Drug Testing Methadone/Buprenorphine 101 Workshop Ron Joe, MD, DABAM December 10, 2016 Learning objectives Clarify the purpose of urine drug testing (UDT) Distinguish between UDT for detection of

More information

Conflict of Interest Disclosure

Conflict of Interest Disclosure Patient Rx Drug Misuse and Abuse: Compliance Toxicology Monitoring in Clinical Practice Toxicology Staff Andrea Terrell, Ph.D., DABCC Chief Scientific Officer George Behonick, Ph.D., DABFT, Manager, FBU

More information

1/27/ New Release, Quest Diagnostics Nichols Institute, Valencia

1/27/ New Release, Quest Diagnostics Nichols Institute, Valencia NEW TESTS Please Note: Not all test codes assigned to each assay are listed in the table of contents. Please refer to the complete listing on the page numbers indicated. Test Code Test Name Effective Date

More information

Evaluation of Abuse of Prescription and Illicit Drugs in Chronic Pain Patients Receiving Short-Acting (Hydrocodone) or Long-Acting (Methadone) Opioids

Evaluation of Abuse of Prescription and Illicit Drugs in Chronic Pain Patients Receiving Short-Acting (Hydrocodone) or Long-Acting (Methadone) Opioids Manchikanti et al Drug Abuse in Patients on Short Acting or Long Acting Opioids 257 Pain Physician. 2005;8:257-261, ISSN 1533-3159 A Prospective Evaluation Evaluation of Abuse of Prescription and Illicit

More information

Linking Opioid Treatment in Primary Care. Roxanne Lewin M.D.

Linking Opioid Treatment in Primary Care. Roxanne Lewin M.D. Roxanne Lewin M.D. The Facts Fewer than 10 percent of individuals with an alcohol use disorder and only about 20 percent of individuals with an opioid use disorder receive specialty treatment. Many individuals

More information

Guidelines for Urine Drug Monitoring for the Pain Patient in a Clinical Practice

Guidelines for Urine Drug Monitoring for the Pain Patient in a Clinical Practice Guidelines for Urine Drug Monitoring for the Pain Patient in a Clinical Practice Howard A. Heit, M.D., F.A.C.P., F.A.S.A.M. Board Certified in Internal Medicine and Gastroenterology/Hepatology Certified

More information

SmartNotes. Thermo Scientific Specimen Validity Tests for Drugs of Abuse Testing

SmartNotes. Thermo Scientific Specimen Validity Tests for Drugs of Abuse Testing DIAGNOSTICS s SmartNotes Thermo Scientific s for Drugs of Abuse ing for Urine Tampering Using s Urine is the most commonly used specimen for drugs of abuse testing. This is primarily because urine is readily

More information

Opioids: Use and Misuse/Steven Feinberg, MD; Scott Levy, MD, MPH, FACOEM

Opioids: Use and Misuse/Steven Feinberg, MD; Scott Levy, MD, MPH, FACOEM Western Occupational Health Conference September 14, 2012 Opioid - Use & Misuse Scott Levy, MD MPH FACOEM Steven Feinberg, MD, MPH Disclosure Information Western Occupational Health Conference 2012 Steven

More information

September HCMC Toxicology Transition: Additional information and Frequently Asked Questions

September HCMC Toxicology Transition: Additional information and Frequently Asked Questions September 2016 HCMC Toxicology Transition: Additional information and Frequently Asked Questions Many clinicians have asked for more information about the Urine Drug Compliance Analysis (LAB8742) switch

More information

Learning Objectives. Drug Testing 10/17/2012. Utilization of the urine drug screen: The good, the bad, and the ugly

Learning Objectives. Drug Testing 10/17/2012. Utilization of the urine drug screen: The good, the bad, and the ugly Utilization of the urine drug screen: The good, the bad, and the ugly Jennifer A. Lowry, MD Chief, Section of Medical Toxicology Children s Mercy Hospital Kansas City, MO Learning Objectives Describe the

More information

Drug Screening: Things You Need to Know

Drug Screening: Things You Need to Know Drug Screening: Things You Need to Know (a view inside the clinical laboratory) Gary L. Horowitz, MD Director, Clinical Chemistry, Beth Israel Deaconess Medical Center Associate Professor of Pathology,

More information

Urine Drug Testing In Pain Management and Substance Abuse Treatment Corporate Medical Policy

Urine Drug Testing In Pain Management and Substance Abuse Treatment Corporate Medical Policy Urine Drug Testing In Pain Management and Substance Abuse Treatment Corporate Medical Policy File Name: Urine Drug Testing in Pain Management and Substance Abuse Treatment File Code: UM.SPSVC.09 Last Review:

More information

FEP Medical Policy Manual

FEP Medical Policy Manual FEP Medical Policy Manual FEP POLICY 2.04.98 Drug Testing in Pain Management and Substance Abuse Treatment Effective Date: April 15, 2017 Related Policies: None Drug Testing in Pain Management and Substance

More information

Drug Testing: How to Evaluate Results

Drug Testing: How to Evaluate Results Drug Testing: How to Evaluate Results Prepared for you by the West Virginia Drug Testing Laboratory Drug testing, whether for an individual or a large corporation, consists of two necessary steps - specimen

More information

HOPE. Considerations. Considerations ISING. Safe Opioid Prescribing Guidelines for ACUTE Non-Malignant Pain

HOPE. Considerations. Considerations ISING. Safe Opioid Prescribing Guidelines for ACUTE Non-Malignant Pain Due to the high level of prescription drug use and abuse in Lake County, these guidelines have been developed to standardize prescribing habits and limit risk of unintended harm when prescribing opioid

More information

Overview of the AACC Academy s LMPG: Using clinical laboratory tests to monitor drug therapy in pain management patients

Overview of the AACC Academy s LMPG: Using clinical laboratory tests to monitor drug therapy in pain management patients Overview of the AACC Academy s LMPG: Using clinical laboratory tests to monitor drug therapy in pain management patients Gwen McMillin, PhD, DABCC(CC,TC) Professor, University of Utah Medical Director,

More information

3703 Camino del Rio South 100-A San Diego, CA, Phone Fax CLIA# 05D years

3703 Camino del Rio South 100-A San Diego, CA, Phone Fax CLIA# 05D years Drug Adherence Assessment Report CleanAssure TM (DRIED BLOOD SPOT): Detection Range see NOTES. Prescribed Medications: NO MEDICATION LIST PROVIDED CONSISTENT RESULTS - MEDICATION DETECTED (PARENT DRUG

More information

What Your Drug Test Really Means. Krista Beiermann, RN, OHS Occupational Health Services, Columbus Hospital

What Your Drug Test Really Means. Krista Beiermann, RN, OHS Occupational Health Services, Columbus Hospital What Your Drug Test Really Means Krista Beiermann, RN, OHS Occupational Health Services, Columbus Hospital Disclosure There are no relevant financial relationships with commercial interests associated.

More information

Urine Drug Monitoring in Chronic Non-Cancer Pain: A Review of Outcome Studies and Gaps in the Literature

Urine Drug Monitoring in Chronic Non-Cancer Pain: A Review of Outcome Studies and Gaps in the Literature Urine Drug Monitoring in Chronic Non-Cancer Pain: A Review of Outcome Studies and Gaps in the Literature Joanna L. Starrels, MD, MS Daniel P. Alford, MD, MPH, FACP Barbara J. Turner, MD, MSEd June 26,

More information

SmartNotes. Understanding the SAMHSA Guidelines for Drugs of Abuse Testing

SmartNotes. Understanding the SAMHSA Guidelines for Drugs of Abuse Testing DIAGNOSTICS SAMHSA Guidelines SmartNotes Understanding the SAMHSA Guidelines for Drugs of Abuse Testing The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency within the US

More information

10/16/2017. Objectives. Drug Testing Interpretation in Addiction Care. Background. Which is Nonadherent?

10/16/2017. Objectives. Drug Testing Interpretation in Addiction Care. Background. Which is Nonadherent? Objectives Drug Testing Interpretation in Addiction Care Brandi Puet, Pharm.D. Describe the difference between immunoassay and confirmatory testing. List explanations for unexpected negative or positive

More information

Proposed Revision to Med (i)

Proposed Revision to Med (i) Proposed Revision to Med 501.02 (i) I. Purpose This rule has been adopted to enable the Board to best protect public health and safety while providing a framework for licensees to effectively treat and

More information

Rule Governing the Prescribing of Opioids for Pain

Rule Governing the Prescribing of Opioids for Pain Rule Governing the Prescribing of Opioids for Pain 1.0 Authority This rule is adopted pursuant to Sections 14(e) and 11(e) of Act 75 (2013) and Sections 2(e) and 2a of Act 173 (2016). 2.0 Purpose This

More information

Opioid Management of Chronic (Non- Cancer) Pain

Opioid Management of Chronic (Non- Cancer) Pain Optima Health Opioid Management of Chronic (Non- Cancer) Pain Guideline History Original Approve Date 5/08 Review/Revise Dates 11/09, 9/11, 9/13, 09/15, 9/17 Next Review Date 9/19 These Guidelines are

More information

MEDICAL POLICY Drug Testing

MEDICAL POLICY Drug Testing POLICY: PG0069 ORIGINAL EFFECTIVE: 01/01/11 LAST REVIEW: 11/13/18 MEDICAL POLICY Drug Testing GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each

More information

Rapid Alcohol Screening Devices. p19

Rapid Alcohol Screening Devices. p19 CLIA-WAIVED Product Catalog RAPID DRUG SCREENING DEVICES Rapid Urine Drug Screening Devices. p5 Rapid Alcohol Screening Devices. p19 Complementary Products. p23 HELPING YOU MAKE INFORMED DECISIONS ABOUT

More information

Conserving Energy Preserving the Future

Conserving Energy Preserving the Future Conserving Energy Preserving the Future Drug and Alcohol Policy 1. Introduction Company is committed to providing safe, dependable and economical service to its Sponsor and Sponsor s customers, maintaining

More information

Drug Testing in Pain Management and Substance Use Disorder Treatment

Drug Testing in Pain Management and Substance Use Disorder Treatment Drug Testing in Pain Management and Substance Use Disorder Treatment Policy Number: 2.04.98 Last Review: 3/2018 Origination: 3/2017 Next Review: 3/2019 Policy Blue Cross and Blue Shield of Kansas City

More information

UnitedHealthcare Pharmacy Clinical Pharmacy Programs

UnitedHealthcare Pharmacy Clinical Pharmacy Programs UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 2099-5 Program Prior Authorization/Medical Necessity Buprenorphine Products (Pain Indications) Medication Belbuca (buprenorphine

More information

Recommendations in Opioid Prescribing Guidelines for Chronic Pain

Recommendations in Opioid Prescribing Guidelines for Chronic Pain Recommendations in Opioid Prescribing Guidelines for Chronic Pain The use of opioids for treating chronic pain has been increasing. 1 In 2010, an estimated 20% of patients presenting to physician offices

More information

Opioid Step Policy. Description. Section: Prescription Drugs Effective Date: April 1, 2018

Opioid Step Policy. Description. Section: Prescription Drugs Effective Date: April 1, 2018 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Opioid Step Policy Page: 1 of 6 Last Review Date: March 16, 2018 Opioid Step Policy Description

More information

2013 Clinical drug and alcohol testing solutions. Product Catalog. CLIA-waived point of care test devices

2013 Clinical drug and alcohol testing solutions. Product Catalog. CLIA-waived point of care test devices 2013 Clinical drug and alcohol testing solutions Product Catalog CLIA-waived point of care test devices HELPING YOU MAKE INFORMED DECISIONS ABOUT ABUSE. Substance abuse testing with more substance. 2 of

More information

Treatment Agreements Clinical Contracts. Dr. Paul A. Farnan, Dr. Johan Wouterloot Prescribers Course, Vancouver, BC, Canada October 13, 2017

Treatment Agreements Clinical Contracts. Dr. Paul A. Farnan, Dr. Johan Wouterloot Prescribers Course, Vancouver, BC, Canada October 13, 2017 Treatment Agreements Clinical Contracts Dr. Paul A. Farnan, Dr. Johan Wouterloot Prescribers Course, Vancouver, BC, Canada October 13, 2017 Faculty/presenter disclosure Presenter: Dr. Paul Farnan Relationships

More information

Policy Title. Control Number HR003. Exception The Scotland County Sheriff s Department is subject to a separate policy.

Policy Title. Control Number HR003. Exception The Scotland County Sheriff s Department is subject to a separate policy. Purpose To ensure compliance with federal regulations as outlined under the Drug-Free Workplace Act and by the U.S. Department of Transportation; to identify the conditions by which personnel are subject

More information

Clearing Up The Confusion About Substance Abuse Testing

Clearing Up The Confusion About Substance Abuse Testing Clearing Up The Confusion About Substance Abuse Testing 2018 Indiana Safety and Health Conference and Expo Presented by Tiffany Ellefson, DISA/Midwest Toxicology Services Items to cover Latest Trends in

More information

Virginia. Prescribing and Dispensing Profile. Research current through November 2015.

Virginia. Prescribing and Dispensing Profile. Research current through November 2015. Prescribing and Dispensing Profile Virginia Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points

More information

DOUGLAS COUNTY GOVERNMENT POLICY FORM. To ensure a drug-free work environment within Douglas County Government.

DOUGLAS COUNTY GOVERNMENT POLICY FORM. To ensure a drug-free work environment within Douglas County Government. DOUGLAS COUNTY GOVERNMENT POLICY FORM SUBJECT DRUG-FREE WORKPLACE TITLE DRUG-FREE WORKPLACE POLICY NO. HR.6.10 APPROVAL DATE 1/1/11 REVISION DATE 1/16/18 PURPOSE: DEPARTMENT RESPONSIBLE: DEPARTMENT(S)

More information

Welcome! Supreme Court of Ohio Specialized Dockets Conference. October 23-24, 2017

Welcome! Supreme Court of Ohio Specialized Dockets Conference. October 23-24, 2017 Welcome! Supreme Court of Ohio Specialized Dockets Conference October 23-24, 2017 Drug Testing: Do you know enough to be dangerous? Presented by William L. Parker President & CEO American Court & Drug

More information

Laboratory Service Report

Laboratory Service Report 4 05/25/19 Client C702884-DLP ROCHESTER Amphetamines, Confirmation Positive Confirmed POSITIVE by LC-S/S for the following: Amphetamine = 52 ethamphetamine = 124 ethamphetamine exists in the d- and l-isomeric

More information

Diagnostic Accuracy Study Protocol. Pain Physician 2010; 13:E1-E22 ISSN

Diagnostic Accuracy Study Protocol. Pain Physician 2010; 13:E1-E22 ISSN Pain Physician 2010; 13:E1-E22 ISSN 2150-1149 Diagnostic Accuracy Study Protocol Protocol for Accuracy of Point of Care (POC) or In-Office Urine Drug Testing (Immunoassay) in Chronic Pain Patients: A Prospective

More information

Urine Drug Screening: The Essentials of Interpretation

Urine Drug Screening: The Essentials of Interpretation Urine Drug Screening: The Essentials of Interpretation Loralie J Langman, PhD DABCC (CC, MD, TC), F-ABFT Director Clinical and Forensic Toxicology Laboratory, Mayo Clinic Professor, Mayo Clinic College

More information

MEDICAL POLICY Drug Testing

MEDICAL POLICY Drug Testing POLICY: PG0069 ORIGINAL EFFECTIVE: 01/01/11 LAST REVIEW: 04/10/18 MEDICAL POLICY Drug Testing GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each

More information

POINT OF CARE TESTING

POINT OF CARE TESTING POINT OF CARE TESTING POINT OF CARE INSTANT TESTING Randox Testing Services offers a wide range of products to enable you to carry out on-site drug and alcohol testing for instant results. Our products

More information

The Utility of Urine Drug Screening

The Utility of Urine Drug Screening The Utility of Urine Drug Screening Treating Addiction, Saving Lives Sea Cruises Bye Tazmania, still far from New Zealand February 8 th, 2018 Mandy Manak, MD FASAM, ISAM, CSAM, MRO Medical Director, ICDO

More information

Beating Drug Tests and Defending Positive Results

Beating Drug Tests and Defending Positive Results Beating Drug Tests and Defending Positive Results Amitava Dasgupta Beating Drug Tests and Defending Positive Results A Toxicologist s Perspective Amitava Dasgupta Department of Pathology and Laboratory

More information

Pharmacokinetics and Disposition of UDM Comparison of Various Sources for Drug Testing: Urine, Blood, Hair, Saliva. Edward J. Cone, Ph.D.

Pharmacokinetics and Disposition of UDM Comparison of Various Sources for Drug Testing: Urine, Blood, Hair, Saliva. Edward J. Cone, Ph.D. Pharmacokinetics and Disposition of UDM Comparison of Various Sources for Drug Testing: Urine, Blood, Hair, Saliva Edward J. Cone, Ph.D. Johns Hopkins School of Medicine, Baltimore, MD & ConeChem Research,

More information

Identifying New Cannabis Use with Urine Creatinine- Normalized THCCOOH Concentrations and Time Intervals Between Specimen Collections *

Identifying New Cannabis Use with Urine Creatinine- Normalized THCCOOH Concentrations and Time Intervals Between Specimen Collections * Identifying New Cannabis Use with Urine Creatinine- Normalized THCCOOH Concentrations and Time Intervals Between Specimen Collections * Michael L. Smith 1, Allan J. Barnes 2, and Marilyn A. Huestis 2,

More information

Frequently Asked Questions: Opiate Dependency and Methadone Maintenance Treatment program follow-up

Frequently Asked Questions: Opiate Dependency and Methadone Maintenance Treatment program follow-up Frequently Asked Questions: Opiate Dependency and Methadone Maintenance Treatment program follow-up Dr. Bhushan M. Kapur Associate Professor Department of Laboratory Medicine and Pathobiology, Faculty

More information

DRUGS OF ABUSE

DRUGS OF ABUSE DRUGS OF ABUSE www.btnx.com 1-888-339-9964 Rapid Response Drugs of Abuse and Alcohol Screening Devices BTNX Inc. prides itself in offering quality drug detection tests for accurate, safe and rapid testing.

More information

Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK

Schedule of Accreditation issued by United Kingdom Accreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK Schedule of ccreditation United Kingdom ccreditation Service 2 Pine Trees, Chertsey Lane, Staines-upon-Thames, TW18 3HR, UK ccredited to Laboratory locations: Gavenny Court Brecon Road bergavenny Monmouthshire

More information

Drug Adherence Assessment Report

Drug Adherence Assessment Report Prescribed Medications: Drug Adherence Assessment Report FENTANYL, OXYCODONE CONSISTENT RESULTS - REPORTED MEDICATION DETECTED (PARENT DRUG AND/OR METABOLITE) REPORTED ANTICIPATED TEST PRESCRIPTION (S)

More information

NBPDP Drug Utilization Review Process Update

NBPDP Drug Utilization Review Process Update Bulletin # 802 December 1, 2010 NBPDP Drug Utilization Review Process Update The New Brunswick Prescription Drug Program (NBPDP) employs a Drug Utilization Review (DUR) process which identifies, investigates

More information

Clinical Policy: Outpatient Testing for Drugs of Abuse Reference Number: PA.CP.MP.50

Clinical Policy: Outpatient Testing for Drugs of Abuse Reference Number: PA.CP.MP.50 Clinical Policy: Reference Number: PA.CP.MP.50 Effective Date: 01/18 Last Review Date: 09/18 Coding Implications Revision Log Description Urine drug testing is a key diagnostic and therapeutic tool that

More information

Drug Testing Index A comprehensive analysis of workplace drug use trends

Drug Testing Index A comprehensive analysis of workplace drug use trends Employer Solutions Semi-Annual Report Fall 2013 Drug Testing Index A comprehensive analysis of workplace drug use trends Anniversary DTI The Quest Diagnostics Drug Testing Index is published as a public

More information

INCENTIVES, Sanctions and Therapeutic Responses BEST PRACTICE STANDARDS IN A NUTSHELL HELEN HARBERTS

INCENTIVES, Sanctions and Therapeutic Responses BEST PRACTICE STANDARDS IN A NUTSHELL HELEN HARBERTS INCENTIVES, Sanctions and Therapeutic Responses BEST PRACTICE STANDARDS IN A NUTSHELL HELEN HARBERTS PORTER93@MSN.COM HELENHARBERTS@GMAIL.COM Adult Drug Court Best Practices Standards, Volume 1, Section

More information

B. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or

B. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or Integrated Reference #: MP/D010 Page: 1 of 7 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services,

More information

A brief history of urine drug testing. Forging a common vocabulary for urine drug testing

A brief history of urine drug testing. Forging a common vocabulary for urine drug testing A brief history of urine drug testing Forging a common vocabulary for urine drug testing Gary M. Reisfield, M.D. Assistant Professor and Director Division of Pain and Palliative Medicine Department of

More information

Utah. Prescribing and Dispensing Profile. Research current through November 2015.

Utah. Prescribing and Dispensing Profile. Research current through November 2015. Prescribing and Dispensing Profile Utah Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points of view

More information

Payment Policy Drug Testing EFFECTIVE DATE: POLICY LAST UPDATED:

Payment Policy Drug Testing EFFECTIVE DATE: POLICY LAST UPDATED: Payment Policy Drug Testing EFFECTIVE DATE: 05 23 2013 POLICY LAST UPDATED: 06 05 2018 OVERVIEW This policy documents the criteria and documentation requirements for immunoassay (IA) testing (also called

More information

2. DEFINITIONS. For the purposes of this policy the following terms are defined herein:

2. DEFINITIONS. For the purposes of this policy the following terms are defined herein: SECTION IV: ALCOHOL AND DRUG FREE WORKPLACE 1. GENERAL POLICY. The purpose of this policy is to implement the Federal Drug Free Workplace Act of 1988 by providing for a safe and productive work environment

More information

UnitedHealthcare Pharmacy Clinical Pharmacy Programs

UnitedHealthcare Pharmacy Clinical Pharmacy Programs UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 4000-3 Program Opioid Overutilization Cumulative Drug Utilization Review Criteria Medication Includes all salt forms, single and

More information

A Toxicologists View of Addiction

A Toxicologists View of Addiction A Toxicologists View of Addiction Deborah Motika, MS, MS, TC(NRCC) Senior Vice President, Toxicologist AGENDA Background : Addiction Toxicology 101 Drug testing 101 Question and Answer Session 2 ADDICTION

More information

Drug & Alcohol Testing in. Canada. Point of Care Testing

Drug & Alcohol Testing in. Canada. Point of Care Testing Drug & Alcohol Testing in Canada Point of Care Testing Introduction We are the leading Canadian innovator of diagnostic testing products and services Verify Diagnostics has assisted governments, corporations,

More information

QuickTox Drug Screen Dipcard (with and without Adulteration Tests)

QuickTox Drug Screen Dipcard (with and without Adulteration Tests) QuickTox Drug Screen Dipcard (with and without Adulteration Tests) Training and Certification Program Presented by CLIAwaived.com, San Diego, CA Distributed by CLIAwaived.com www.cliawaived.com 1-858-481-5031

More information

California. Prescribing and Dispensing Profile. Research current through November 2015.

California. Prescribing and Dispensing Profile. Research current through November 2015. Prescribing and Dispensing Profile California Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points

More information

Delaware Emergency Department Opioid Prescribing Guidelines

Delaware Emergency Department Opioid Prescribing Guidelines Delaware Emergency Department Opioid Prescribing Guidelines This guideline is intended for physicians working in hospital-based Emergency Departments (EDs) and free-standing emergency centers in the state

More information

ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program

ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program ToxCup Training Page 1 of 8 Rev. B ToxCup Drug Screen Cup ToxCup Drug Screen Cup with Adulteration Tests

More information

Medical Policy. MP Drug Testing in Pain Management and Substance Use Disorder Treatment

Medical Policy. MP Drug Testing in Pain Management and Substance Use Disorder Treatment Medical Policy BCBSA Ref. Policy: 2.04.98 Last Review: 12/20/2018 Effective Date: 12/20/2018 Section: Medicine Related Policies 2.01.30 Biofeedback as a Treatment of Chronic Pain 5.01.16 Intravenous Anesthetics

More information

Many companies conduct drug screenings. But you better avoid the following nine items and save yourself a world of frustration, if you need

Many companies conduct drug screenings. But you better avoid the following nine items and save yourself a world of frustration, if you need 18-8-2017 Many companies conduct drug screenings. But you better avoid the following nine items and save yourself a world of frustration, if you need to pass the test 2-2-2018 25 Answers (question resolved)

More information

ALCOHOL AND DRUG-TESTING OF BUS DRIVERS REGULATION

ALCOHOL AND DRUG-TESTING OF BUS DRIVERS REGULATION REGULATION It is the District s intention to comply fully with the Omnibus Transportation Employee Testing Act of 1991 (P.L. 102-143) (the Omnibus Act ) and U. S. Department of Transportation (the DOT)

More information

ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program

ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program ToxCup Drug Screen Cup (with and without Adulteration Tests) Training and Certification Program ToxCup Training Page 1 of 8 Rev. B ToxCup Drug Screen Cup ToxCup Drug Screen Cup with Adulteration Tests

More information

Does ultram show up as an opiate

Does ultram show up as an opiate Search Does ultram show up as an opiate Tramadol ( Ultram ) is prescribed for treating moderate to severe pain in adults. 19-2-2018 I took Tramadol Hydrochloride for 6 months due to joint pain from my

More information