Researchers Emphasize Routine Urine Drug Testing to Ensure Opioid Compliance, Enhance Pain Care

In light of the fact that many physicians continue to rely on observational analysis and patient self-reporting to monitor opioid addiction or misuse, results from a scientific poster presented at the American Academy of Pain Medicine (AAPM) Annual Meeting, held March 6-9, 2014, in Phoenix, AZ, reinforced the benefits of routine urine drug testing in improving compliance with prescribed opioid medications and ultimately enhancing pain care.

In order to accurately assess medication adherence among chronic opioid users in the outpatient setting, Nebojsa Nick Knezevic, MD, PhD, Omar M. Khan, MD, Afsaneh Beiranvand, MD, and Kenneth D. Candido, MD, from the Advocate Illinois Masonic Medical Center Pain Clinic in Chicago, IL, randomly asked 302 opioid-consuming patients to provide urine specimens for toxicological analysis during their regular clinical visits — 56% of which had been prompted by complaints of low back pain.

Although none of the patients received prior notification that a urine specimen would be collected during the clinical visit, the researchers discussed the test results with the patients and counseled them on medication compliance at a subsequent appointment.

After collecting the urine samples, Knezevic and his coauthors sent the specimens to an outside laboratory to test for the presence and concentration of various medications and illegal drugs — as well as their metabolites — which included opioids such as oxycodone, hydrocodone, hydromorphone, oxymorphone, methadone, fentanyl, morphine, codeine, tramadol, propoxyphene, buprenorphine; benzodiazepines such as lorazepam, temazepam, oxazepam, tapentadol, and barbiturates; and amphetamines such as methamphetamine, MDMA, cannabinoids, phencyclidine, cocaine, and benzoylecgonine. To indicate whether the urine samples had been diluted, the investigators had them screened for creatinine, as well.

Once the quantitative lab tests were completed, the authors cross-referenced the results with each patient’s medical record for prescribed medications and the state-wide Illinois Prescription Monitoring Program (IPMP).

“Of the 302 patients, 212 patients (70%) were compliant for prescribed medications, (but) 53 (18%) patients tested positive for medications that were not prescribed in the clinic and could not be verified in the IPMP,” the researchers found. In addition, “38 (13%) patients tested positive for illicit drugs: marijuana (37 patients), cocaine (9 patients), and heroin (1 patient).”

Although most of the patients who tested positive for marijuana had previously disclosed their use of the drug for medical purposes, the 10 patients who tested positive for cocaine or heroin use had directly violated the clinic’s mutual opioid agreement and were thus immediately discharged.

Despite the initially high percentage of non-compliant patients taking chronic opioid medications for pain management, the researchers reported that recurrent urine toxicology tests demonstrated improved adherence in 69 out of 88 patients. Additionally, the repeat monitoring efforts “allowed enhanced adjustment of opioid doses in 51 out of 88 patients (58%), which improved pain control and compliance in 32 out of 51 patients (63%).”

In response to that heightened patient compliance, Knezevic and his coauthors concluded routine urine screening “could be a relevant tool to accurately adjust the dosing of opioid medication, enhance proper management of pain, and improve patient compliance.” The researchers also emphasized the “importance of these tests in all pain clinics, in terms of providing an inducement to patients using opioids.”