Urine Drug Testing PracticeNotes Clinical Guide
|
|
- Dustin Carter
- 6 years ago
- Views:
Transcription
1 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 use in the assessment and ongoing management of the chronic pain patient. The information presented in this guide is not meant to be a comprehensive tutorial, but an annotated, quick reference of critical points to consider when utilizing UDT in pain management. For more detailed information on UDT, visit: What is Urine Drug Testing (UDT)? 1,2 UDT: Is a method which involves the analysis of a urine specimen to detect the presence or, in some cases, the absence of a drug and/or the metabolite(s) at or above a predetermined threshold Plays a key role in safely managing a chronic pain patient, to: s Stratify individual risk s Identify relapse or drug misuse s Assist in monitoring for compliance with the agreed upon treatment plan s Advocate for the pain patient with family, workplace, and other relevant third parties Important to note 3-5 : Thresholds and testing strategies in federally regulated UDT make the assumption that most participants are non-drug users. In the chronic pain population, most participants are appropriate users of prescription drugs UDT can be regulated (ie, workplace testing) and non-regulated (ie, clinical testing) Regulated UDT was not designed for use in the chronic pain patient population. The SAMHSA-based testing model was never meant to be used clinically. It was designed to be used primarily to identify inappropriate drug use in the workplace Regulated urine drug screening immunoassay tests are designed to detect illicit drug use in a population pool of largely non-drug users Regulated urine drug detection thresholds are usually set at high levels consistent to minimize false-positive results No one standard UDT exists for all drug testing scenarios. UDT does not test for every drug, hence, a testing strategy must be in place to insure that the tests ordered meet the patient/clinicians needs Utility of UDT 3,4 UDT results may be used: As an objective data point to support baseline patient data collection To assess patient adherence with the treatment plan/treatment agreement To show recent previous exposure to a drug(s) or its metabolite(s), or to members of certain classes of drugs
2 Limitations of UDT 3,4,6,7 UDT cannot provide information about: Motivation behind exposure, eg, legitimate medical exposure to cocaine as a topical anesthetic vs. illicit use of cocaine. Both will result in a positive UDT for benzoylecgonine and/or cocaine parent Amount of drug used Time of last drug use Source of drug (licit or illicit) Confirmation of addiction, physical dependence, or impaired function Synthetic or semi-synthetic opioid use s Immunoassay urine methods have a low sensitivity for semi-synthetic opioids s Opiate immunoassay screens will not detect synthetic agents like fentanyl or methadone unless the assay is specific for the particular molecule s Immunoassay UDTs are sensitive for naturally occurring opiates such as codeine/morphine and less reliably for semi-synthetic agents like oxycodone, hydrocodone, oxymorphone or hydromorphone s Specific immunoassay tests are available for some synthetic or semi-synthetic agents such as methadone or oxycodone s GC/MS and other more sophisticated laboratory tests do detect these and many other molecules Negative opiate immunoassay results do not preclude use of semi-synthetic or synthetic opioids Drug-specific testing is available; communicate with the laboratory regarding availability and costs of drug-specific testing and their particular need Remember to alert the laboratory to the drug(s) in question to identify the parent and/or the metabolite(s) in question, if possible Important to note: Order the appropriate test Always consider UDT results in context with drug metabolism and comprehensive patient data Metabolite pathways can produce positive results for analytes that might appear to indicate drug abuse when in reality, it is simply the detection of a metabolic pathway, eg, codeine may result in a positive for hydrocodone (please refer to the pathway of opioid metabolism on page 5) Communication with the laboratory, especially with unexpected results, is critical to the proper interpretation of laboratory data. In some cases, the expected result may be misleading, ie, where a patient is prescribed an opioid such as fentanyl and is positive for opiates. This appears to be as expected, but because fentanyl is a synthetic opioid, it cannot explain the positive opiate results. A call to the laboratory is essential unless the patient s clinical story is consistent with the results Factors Affecting UDT Results 4,16 Integrity of urine sample Type of drug and pharmacokinetics Cross-reactivity of other agents Last time and amount of drug used Patient metabolism and genetic profile Laboratory or human error Always re-test the original specimen if there is any doubt regarding the initial tests results. 2
3 Urine Sample 1,3,4,7,16-19 Concentrated sample is best if practical Unobserved collection is acceptable Use colorant in toilet water and limit availability to other water sources to limit potential for sample dilution Sample should be consistent with human urine: s Temperature degrees Fahrenheit within 4 minutes of collection in a suitable sample volume (ie, 30 ml) s ph s Random urinary creatinine greater than 20 mg/dl; less than 20 mg/dl is considered dilute and less than 5 mg/dl is not consistent with human urine Testing Options: Strengths and Limitations 4,16 Test Type Results TAT Costs Test Results Appropriate Use POC or IA Immediate $$ Including personnel time to perform testing IA testing, done at POC or laboratory, use essentially the same reagents, however, the cutoff points may be different especially for opioids, which are 300 ng/ml therapeutically, but regulated tests are at 2,000 ng/ml Lacks specificity but have higher sensitivity Typically detects classes rather than individual drug(s)/metabolite(s) Quality assurance (QA) must be performed by testing site If results will alter course of therapy or are in dispute; may want to confirm with additional testing using GC/MS or LC/MS The biggest advantage to POC is the immediacy of the test result and the ability of the clinician to target specific therapeutic interventions based on POC results The biggest disadvantage to POC is responsibility for testing quality lies with testing site, accuracy and/or cost IA Laboratory Fast; usually < 24 hours $$ QA is performed by the laboratory Detects classes of drug/metabolite per panel selection if ordered High sensitivity Order separate test for semisynthetic/synthetic opioid drug detection, ie, fentanyl, methadone GC/MS or LC/MS Time consuming; complex sample preparation $$$ High specificity Detects specific drug and/or drug metabolite; thresholds can often be set lower than with IA testing Reliable true-positives; true-negatives QA is performed by the laboratory Confirmatory testing after a positive finding from IA, if disputed by patient POC = point of care/collection; GC/MS = gas chromatography-mass spectrometry; LC/MS = liquid chromatography-mass spectrometry; QA = quality assurance; IA = immunoassay; TAT = turnaround time 3
4 UDT: Frequency and Timing 2,6,8-15 UDT may be ordered: In line with your particular practice s risk strategy for UDT assessment. If your practice has high-risk patients, then monitoring requirements would be substantially different from a practice where the majority of patients are NOT at high risk for substance use disorders Prior to treatment; as part of the baseline assessment in opioid-naïve patients or in those previously or currently prescribed opioid therapy Throughout course of treatment; based on results of initial and ongoing risk assessments and patient need, in response to display or reports of aberrant drug-related behaviors The frequency of scheduling UDT should be based on the treatment agreement boundaries and the level of risk for each patient (ie, low-risk patients may only be required to be tested 1-2 times a year, whereas a high-risk patient may need to be tested more frequently) As needed (ie, in response to an aberrant drug-related behavior; at times of treatment modification; in response to third-party assertions of illegal or aberrant drug-taking behavior) Randomly, for patients who are in recovery Important to note : A UDT strategy minimizes profiling based upon clinician bias the decision to test should be based on the overall strategy, not based on the look of a patient UDT is only one part of Universal Precautions, risk management requires looking at the patient as a whole Sole reliance on patient self-report may result in missing a significant number of illicit drug users Reductions in illicit drug use by routine use of UDT in chronic pain patients have been reported Stigma associated with UDT may be minimized if UDT is ordered rationally Confounding Factors in Clinical Testing The following information is useful for the doctor to record in the patient s chart prior to ordering a UDT for later comparison. Crystallize the moment (personal communication Dr. Douglas Gourlay) with these details so that UDT results can be discussed meaningfully with the patient/laboratory at a later date if the results do not match the clinical findings. All prescribed medications and duration of opioid therapy Time of last dose as stated by the patient Compliance algorithms based on this information are currently not ready for clinical use 20,21 : 4
5 Morphine: Positive Finding 4,22-24 Morphine is a metabolite of both codeine and heroin (diacetylmorphine) Hydromorphone can be a minor metabolite of morphine Very low concentrations of hydromorphone may be detected in the urine of patients prescribed high-dose morphine therapy Oxycodone or Other Semi-synthetic or Synthetic Opioids: False-Negative Finding 25,26 Immunoassays, including those specifically for oxycodone, have relatively high thresholds and may not detect low concentrations as sometimes seen with dilute samples. Confirmation of negative immunoassay results using GC/MS or LC/MS may be necessary No limit testing / no threshold testing is recommended when the apparent absence of prescribed medications or their metabolites may adversely affect patient care Opioid Metabolism 4 Codeine Morphine 6-MAM Heroin Hydrocodone Hydromorphone This is not a comprehensive pathway but may help the clinician to explain the presence of drugs which they have not directly prescribed. Conclusion UDT can be a simple and valuable tool for pain management clinicians in the initial and ongoing assessment of chronic pain patients. It is imperative to communicate with your testing laboratory or test kit provider to accurately utilize and interpret UDT results. It is also imperative to build mutual trust and honesty in the doctor-patient relationship by explaining the rationale behind UDT as stated in a treatment agreement. An effective and patient-centered UDT strategy combined with accurate interpretation of the test results can be used as part of a comprehensive risk management strategy to reduce stigma and improve patient care. 5
6 Glossary Compliance testing Urine specimen testing to determine if patients with chronic pain are adhering to appropriate use of their prescribed controlled substance medication and not using non-prescribed medications or illicit drugs. Confirmatory testing Use of a test with greater specificity to validate an initial positive screen test result. Confirmatory testing is a term more in-line with forensic workplace testing. Pain clinicians are interested in specific identification rather than confirmation since they need to know which drug is giving the class-positive test result. Cut-off The concentration of a drug in urine, usually in nanograms per milliliter (ng/ml), used to determine whether a specimen is positive (at or above the cut-off) or negative (below the cut-off) for the drug in question. This may be arbitrarily set. Drug-detection threshold The minimum concentration used to determine a positive finding as established by the manufacturer or a laboratory based on analytical performance of a specific method. Federally-regulated urine drug testing Workplace testing limited to the Federal Five (THC, cocaine, PCP, opiates, amphetamine/methamphetamine); Department of Health and Human Services and Department of Transportation strictly regulate all facets of process and do not permit testing for other drugs. Gas chromatography/mass spectrometry (GC/MS) urine drug testing GC/MS is a highly sensitive and specific technique usually performed to confirm a positive screening result (ie, from an immunoassay) or to identify a specific drug; GC/MS combines the physical separation capability of GC with MS and identifies the presence of a particular substance based on characteristic fragmentation patterns (fingerprint) at specific retention times. Immunoassay (IA) A technique used to measure substances in a specimen, including drugs of abuse in urine. In immunoassays, an antibody to the drug/drug class is used to detect the presence of that drug/drug class at or above a defined threshold or cut-off. Some IAs, such as those for opiates and benzodiazepines, are designed to detect only a limited number of drugs in the drug class and may not detect some clinically important drugs. The antibodies used in the IAs may also cross-react with other compounds that have a similar structure. Liquid chromatography/mass spectrometry (LC/MS) LC/MS is an analytical chemistry technique that combines the physical separation capabilities of liquid chromatography (or HPLC) with the mass analysis capabilities of mass spectrometry as with GC/MS. Metabolite A chemical substance produced in the process (metabolism) by which the body breaks down (eg, via liver enzymes) and converts drugs to similar but different substances. The product produced may be pharmacologically active (and act as a drug) or not (no effect). Non-regulated urine drug testing UDT for clinical and non-forensic uses. Consult with laboratory prior to testing to determine best test mix (profile) for the information desired. Point of care urine drug testing Immunoassay-based testing performed at the site of patient care; testing may be performed by health care provider or a technician. Similar in technology to that used in screening in laboratory testing, only on a smaller scale and more dependent on operator training and skill. Specimen validity testing Tests conducted by the laboratory to determine if a urine sample has been diluted with water (in vitro or in vivo), or has been adulterated with a foreign substance. Treatment agreement This is a document outlining conditions under which opioids will be prescribed (ie, one physician, one pharmacist) in which physicians need to document overall improvement in pain and function, and patient s responsibilities need to be described. It should include the utilization of unscheduled UDT, consequences of agreement breech, and conditions of treatment discontinuation. Universal Precautions in Pain Medicine This is a term coined in a paper published by Gourlay/Heit that recommends an approach to the chronic pain patient that includes a strategy of risk management that improves care, reduces risk and eliminates stigma. 6
7 This clinical guide has been developed with the assistance of contributing editors including (in alphabetical order): Yale Caplan, PhD, D-ABFT Adjunct Professor, Department of Pharmaceutical Sciences University of Maryland, School of Pharmacy Douglas Gourlay, MD, MSc, FRCPC, FASAM Director, Pain and Chemical Dependency Division Wasser Pain Management Centre, Mount Sinai Hospital Center for Addiction and Mental Health, Toronto, Canada Catherine A. Hammett-Stabler, PhD, DABCC, FACB Associate Professor, Department of Pathology & Laboratory Medicine University of North Carolina, School of Medicine Howard A. Heit, MD, FACP, FASAM Chronic Pain Management and Addiction Medicine Specialist Assistant Professor, Georgetown University Lynn R. Webster, MD, FACPM, FASAM Cofounder and Medical Director Lifetree Clinical Research For further information on UDT, please visit today! References 1. Gourlay DL, Heit HA, Caplan YH. Urine Drug Testing in Clinical Practice: Dispelling the Myths & Designing Strategies. California Academy of Family Physicians (Edition 3). Accessed August 20, 2009 at: 2. Hammett-Stabler CA, Webster L. A Clinical Guide to Urine Drug Testing: Augmenting Pain Management & Enhancing Patient Care (May). Accessed August 20, 2009 at: 3. Heit HA, Gourlay D. Urine Drug Testing in Pain Medicine. J Pain Symptom Manage. 2004:27(3): Swotinsky RB, Smith DR. The Medical Review Officer s Manual. 3rd Ed. Beverly, MA. OEM Press, Hammett-Stabler CA, Pesce AJ, Cannon DJ. Urine drug screening in the medical setting. Clin Chim Acta. 2002;315(1-2): Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002;18(4 Suppl):S 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): Moeller K, Lee KC, Kissack JC. Urine drug screening: Practical guide for clinicians. Mayo Clin Proc. 2008;83(1): Manchikanti L, Atluri S, Trescot AM, Giordano J. Monitoring opioid adherence in chronic pain patients: Tools, techniques, and utility. Pain Physician. 2008;11(2 Suppl):S 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):
8 11. Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97(4): 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): Kahan M, Srivastava A, Wilson L, Gourlay D, Midmer D. Misuse of and dependence on opioids: Study of chronic pain patients. Can Fam Physician. 2006;52(9): Casavant MJ. Urine drug screening in adolescents. Pediatr Clin North Am. 2002;49(2): 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): Dasgupta A. The Effects of Adulterants and Selected Ingested Compounds on Drugs-of-Abuse Testing in Urine. Amer J Clin Pathol. 2007;128(3): 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): 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): MEDLINE Plus. Urine specific gravity. Accessed August 20, 2009 at: Nafziger AN, Bertino JS. Utility and Application of Urine Drug Testing in Chronic Pain Management With Opioids. Clin J Pain. 2009;25: Gourlay DL, Heit HA. The Art and Science of Urine Drug Testing. Clin J Pain. In Press. 22. 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): 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, 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): Von Seggern RL, Fitzgerald CP, Adelman LC, Adelman JU. Laboratory monitoring of OxyContin (oxycodone): Clinical pitfalls. Headache. 2004;44(1): Vincent EC, Zebelman A, Goodwin C, Stephens MM. Clinical inquiries. What common substances can cause false positives on urine screens for drugs of abuse? J Fam Pract. 2006;55: Accessed August 20, 2009 at: Provided by MediCom Worldwide, Inc. This clinical guide is supported by an independent educational grant from
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 informationGold 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 informationUrine 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 informationAnalysis 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 informationIllicit 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 informationPROFESSIONALISM 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 information3/8/2018. 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 informationPatient-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 informationURINE 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 informationTrust 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 informationUrine 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 informationClinical 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 informationTesting 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 informationEDUCATIONAL 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 informationUrine 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 informationMedical 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 informationOpioids: 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 informationLearning 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 informationCutoff 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 informationCorporate 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 informationClinical 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 informationUrine 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 informationDrug 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 informationThe 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 informationPain 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 informationTreatment 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 informationControlled 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 informationUrine Drug Testing. Clinical Practice
Urine Drug Testing in Clinical Practice The Art and Science of Patient Care EDITION 4 Target Audience: Family physicians and other primary care physicians Sponsored by the California Academy of Family
More informationFEP 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 informationA 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 informationOpiates Rapid Test. Cat. No.:DTS137 Pkg.Size:50T. Intended use. General Description. Principle Of The Test. Reagents And Materials Provided
Opiates Rapid Test Cat. No.:DTS137 Pkg.Size:50T Intended use The CD One Step Opiates Screening Test is a rapid, qualitative immunoassay for the detection of opiates and opiate metabolites in urine. The
More informationUrine 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 informationPain 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 informationDr. Melissa Holowaty HAVELOCK ON 146 BUPRENORPHINE IN RURAL PRACTICE FOR OPIOID USE DISORDER
Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12-14, 2018 Dr. Melissa Holowaty HAVELOCK ON 146 BUPRENORPHINE IN RURAL PRACTICE
More informationOne of These Tests is Not Like the Other: Comparative effectiveness, cost-effectiveness and utilization guidance in pain management testing
& One of These Tests is Not Like the Other: Comparative effectiveness, cost-effectiveness and utilization guidance in pain management testing Speaker Frederick G. Strathmann Learning Objectives Discuss
More informationPain Management Drug Testing: A Laboratory Perspective
Ernest Jimenez III, M.T.(ASCP) Nothing to declare. Laboratory manager at Pharos Diagnostics, LLC., located in Tucson, AZ. Pain Management Drug Testing: A Laboratory Perspective 1 2 Pain Management Drug
More informationThe 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 informationMEDICAL 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 informationUrine 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 informationUrine Drug Testing in Chronic Pain Patients
Supplement to: Sponsored by: Clinical Best Practices for Urine Drug Testing in Chronic Pain Patients Clinical Best Practices for Urine Drug Testing in Chronic Pain Patients 2 Urine Drug Testing in Chronic
More informationUrine Toxicology Testing in Chronic Pain Management
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
More informationHow 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 informationEDUCATIONAL 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 informationClinical Urine Drug Testing During Opioid Therapy: A Case-Based Approach to Patient Monitoring
Clinical Urine Drug Testing During Opioid Therapy: A Case-Based Approach to Patient Monitoring Release Date: January 1, 2010 Expiration Date: January 31, 2011 Needs Statement 3 Implement a routine urine-screening
More informationSeptember 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 informationFrequently 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 informationConflict 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 informationDrug 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 informationUrine 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 informationSmartNotes. 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 informationDisclosures. You're in Control or Urine Control Clinical Pearls of Drug Testing Case Studies. 9/20/17
You're in Control or Urine Control Clinical Pearls of Drug Testing Case Studies Jeffrey Fudin, BS, PharmD, FCCP, FASHP www.paindr.com Disclosures Astra Zeneca (Speakers Bureau) Collegium (Consultant) Daiichi
More informationSmartNotes. 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 informationDrug 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 informationImmunoassay-Based Drug Tests Are Inadequately Sensitive for Medication Compliance Monitoring in Patients Treated for Chronic Pain
Pain Physician 2017; 20:SE1-SE9 ISSN 2150-1149 Review Immunoassay-Based Drug Tests Are Inadequately Sensitive for Medication Compliance Monitoring in Patients Treated for Chronic Pain Marion L. Snyder,
More informationOverview 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 informationMEDICAL 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 informationLaboratory 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 informationWELCOME! 12/13/2018. Today s Topic: Urine Drug Screens in OUD Treatment UW PACC
Psychiatry and Addictions Case Conference UW Medicine Psychiatry and Behavioral Sciences 12/13/2018 WELCOME! Today s Topic: Urine Drug Screens in OUD Treatment Should I test and how should I do drug testing
More informationUsing 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 informationBased on our criteria and assessment of the peer-reviewed literature, presumptive (immunoassay) in office or pointof-care
MEDICAL POLICY SUBJECT: URINE DRUG TESTING PAGE: 1 OF: 10 If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply. If a commercial product, including an
More informationB. 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 informationDRUG TESTING POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: March 1, Related Policies None
DRUG TESTING POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 259.3 T0 Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES OF
More informationInterpretation of Workplace Tests for Cannabinoids
J. Med. Toxicol. (2017) 13:106 110 DOI 10.1007/s13181-016-0587-z PROCEEDINGS Interpretation of Workplace Tests for Cannabinoids Ken Kulig 1 Received: 17 May 2016 /Revised: 16 August 2016 /Accepted: 6 September
More informationMedical Policy Outpatient Drug Screening and Testing. No Prior Authorization X X
Medical Policy Outpatient Drug Screening and Testing Document Number: 030 Authorization required Commercial and Qualified Health Plans MassHealth No Prior Authorization X X Overview The purpose of this
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: opioid_testing_in_pain_management_and_substance_abuse 01/01/2019 N/A 01/01/2020 01/01/2019 Policy Effective
More informationWhat 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 informationClinical Policy: Outpatient Testing for Drugs of Abuse
Clinical Policy: Reference Number: CP.MP.50 Last Review Date: 07/18 See Important Reminder at the end of this policy for important regulatory and legal information. Coding Implications Revision Log Description
More informationDRUG TESTING POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: October 1, Related Policies None
DRUG TESTING POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 259.1 T0 Effective Date: October 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES
More informationASPMN Conference Baltimore, Maryland
ASPMN Conference Baltimore, Maryland Prescribing Controlled Substances Managing Risk and Optimizing Outcomes September 13, 2012 Tracey Fremd, NP Tracey Fremd Consulting, Inc. Most Common Uses for Controlled
More informationPractical Applications of Urine Drug Monitoring in the Addiction Treatment Setting
Practical Applications of Urine Drug Monitoring in the Addiction Treatment Setting John Femino, MD, FASAM, MRO Medical Director, President & CEO, Meadows Edge Recovery Center NE Regional Director, American
More informationMedical Policy. Urine Drug Screening. Policy Number: Policy History
Policy Number: 40071 Policy History Approve Date: 06/13/2016 Effective Date: 12/15/2016 Preauthorization All Plans Benefit plans vary in coverage and some plans may not provide coverage for certain service(s)
More informationREPORT 1 OF THE COUNCIL ON SCIENCE AND PUBLIC HEALTH (I-16) Urine Drug Testing (Reference Committee K) EXECUTIVE SUMMARY
REPORT OF THE COUNCIL ON SCIENCE AND PUBLIC HEALTH (I-) Urine Drug Testing (Reference Committee K) EXECUTIVE SUMMARY Objective. The Council on Science and Public Health initiated this report to help promulgate
More information80305, 80306, 80307,G0480, G0481, G0482, G0483, G0659
80305, 80306, 80307,G0480, G0481, G0482, G0483, G0659 CMS Policy for Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont Local policies are determined by the performing
More informationSubstance abuse is a significant problem in the United
Interpretation and Utility of Drug of Abuse Immunoassays Lessons From Laboratory Drug Testing Surveys Stacy E. F. Melanson, MD, PhD; Leland Baskin, MD; Barbarajean Magnani, PhD, MD; Tai C. Kwong, PhD;
More informationNeoSal Oral Fluid Collection System Solutions for Forensic Drug Detection
PERFORMANCE OF THE NEOSAL ORAL FLUID COLLECTION SYSTEM Neogen develops and manufactures a comprehensive range of ELISA test kits and accessories for forensic drug detection. Neogen offers solutions to
More informationPayment 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 informationEffective 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 informationDRUG TESTING POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: January 1, Related Policies None
DRUG TESTING POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 259.2 T0 Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES
More informationA 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 informationURINE DRUG TESTING FOR SUBSTANCE ABUSE TREATMENT AND CHRONIC PAIN MANAGEMENT
Status Active Medical and Behavioral Health Policy Section: Laboratory Policy Number: VI-47 Effective Date: 07/21/2014 Blue Cross and Blue Shield of Minnesota medical policies do not imply that members
More informationWelcome! 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 informationT R A I N I N G G U I D E
TRAINING GUIDE InstaCube Oral Fluid Drug Test For Forensic Use Only Powered By: Contents 3 The information in this presentation is a general overview on performing and interpreting the InstaCube Oral Fluid
More informationDRUGS 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 informationMichael M. Miller, MD, FASAM, FAPA
Michael M. Miller, MD, FASAM, FAPA mmiller@rogershospital.org Medical Director, Herrington Recovery Center (HRC) Rogers Memorial Hospital Oconomowoc, Wisconsin Vice Speaker Wisconsin Medical Society Clinical
More informationDisclosures. Get Your Specimens in Order:
Get Your Specimens in Order: The Importance of Individualized Test Orders and Timely Test Utilization Jennifer Bolen, JD Disclosures Jennifer Bolen, JD Consultant to Generation Partners Consultant to Abbott
More informationUniversal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain
Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain Douglas L. Gourlay, MD, MSc, FRCPC, FASAM, Howard A. Heit, MD, FACP, FASAM, Abdulaziz Almahrezi, MD, CCFP Blackwell
More informationTrainwreck: Addressing Complex Pharmacotherapy With the Inherited Pain Patient
Trainwreck: Addressing Complex Pharmacotherapy With the Inherited Pain Patient Douglas Gourlay MD, MSc, FRCPC, FASAM Disclosures Nothing to disclose 2 1 Learning Objectives Assess the prescription drug
More information1/27/ 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 informationLaboratory 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 informationModernizing the Forensic Lab with LC-MS/MS Technology
Modernizing the Lab with LC-MS/MS Technology Innovative SCIEX Analytical Tools for the Rapid Identification of Drugs of Abuse in Samples Oscar G. Cabrices 1, Holly McCall 1, Xiang He 1, Alexandre Wang
More informationCase Study Mary Williams
1 Case Study Mary Williams 42 yo woman T2DM Chronic, painful, diabetic neuropathy and back pain Remote h/o alcohol dependence Gabapentin and oxycodone/acetaminophen In the interim Medical records confirmed
More informationUrine Drug Testing - What Do the Results Mean and What Do I Tell the Patient? Andrea Trescot, MD, FIPP
Urine Drug Testing - What Do the Results Mean and What Do I Tell the Patient? Andrea Trescot, MD, FIPP Disclosure Andrea Trescot, MD, FIPP Pain and Headache Center Eagle River, AK President, Alaska Society
More informationMedical 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 informationPresents CLINICAL DRUG TESTING IN PRIMARY CARE
Presents CLINICAL DRUG TESTING IN PRIMARY CARE Internet Based Coursework 3 hours of educational credit Approved by such credentialing bodies as: National Association of Alcoholism and Drug Abuse Counselors
More informationOpioid analgesic therapy in pain management: how we got here from there
National Organization of Alternative Programs March 17, 2016 Opioid analgesic therapy in pain management: how we got here from there Gary M. Reisfield, M.D. Divisions of Addiction Medicine and Forensic
More informationDrug Testing Policy. Approved By 05/10/2017. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products.
Policy Number 2017R6005B Annual Approval Date Drug Testing Policy 05/10/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for
More informationWorkforce Drug Testing Positivity Climbs to Highest Rate Since 2004, According to New Quest Diagnostics Analysis
News from Quest Diagnostics Media: Kim Gorode, 973.520.2800 Investors: Shawn Bevec, 973.520.2900 Workforce Drug Testing Positivity Climbs to Highest Rate Since 2004, According to New Quest Diagnostics
More informationMedication Misuse and Abuse: A Growing Epidemic
Medication Misuse and Abuse: A Growing Epidemic Colorado Providers Association Professionalizing Prevention June 19, 2015 Mancia Ko, PharmD, MBA Associate Director, Medical Affairs,, Ameritox Assistant
More information2013 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 informationProtocol. Drug Testing in Pain Management and Substance Abuse Treatment
Protocol Drug Testing in Pain Management and Substance Abuse Treatment (20498) Medical Benefit Effective Date: 10/01/16 Next Review Date: 07/18 Preauthorization No Review Dates: 07/15, 07/16, 07/17 Preauthorization
More information