Urine Drug Testing, Treatment Compliance, and Managing Risk in Pain Management: A Q&A with Joshua Gunn, PhD

Joshua Gunn, PhD

How has the use of urine drug testing in pain management evolved in recent years?

Urine drug testing (UDT) has become a widely utilized tool across many specialties. Although it was traditionally used more by pain specialists due to concerns over prescription drug abuse, diversion, and misuse, it has become something that family physicians and non-pain specialists rely on more than ever. I’ve dealt a lot with family practice physicians around the country in the last few years who have had to start doing compliance monitoring because of an increase in the amount of pain management that they are doing. The goal behind UDT from a physician’s standpoint is to corroborate whether what a patient is telling them is accurate, whether that is on an initial patient visit or 12 months into the treatment program.

Because of the advanced way in which urine samples are tested toxicologically now, there’s really no arguing the results. However, in the past, many providers who were doing some form of drug testing were utilizing instant testing devices in the office things like urine cups, dipsticks, and other point-of-care tests that we now realize are not ideal for this because of their limitations and the possibilities of false positives and false negatives.

"We have to ensure that there are educational tools and resources in place so that providers are able to understand the toxicology reports. I find that providers’ biggest struggle is that they see the value in this testing, but interpreting the results can be quite complex."

As we move toward recommending urine drug testing from a state medical board or from a government standpoint, or mandating this testing for certain patients who are prescribed controlled substances, we have to ensure that there are educational tools and resources in place so that providers are able to understand the toxicology reports. I find that providers’ biggest struggle is that they see the value in this testing, but interpreting the results can be quite complex. Every patient is different, and we have to make sure that resources are available that enable providers and patients to make an informed decision about treatment.

Properly administered, what can urine and blood testing tell a clinician about his or her pain patients? What are the best uses for each of these testing modalities?

Urine drug testing is our best friend when it comes to general compliance monitoring because drugs stay in the urine a lot longer than they stay in the blood. Typically, an opioid will only remain detectable in the blood for several hours, but it’s going to remain detectable in the urine for several days. Urine affords us a standard window of detection that is ideal for compliance monitoring, because if you’re seeing a patient for the first time, you not only want to know what’s in their system now, you also want to know whether they’ve been using substances or illicit drugs in the three or four days leading up to their visit.

One limitation of urine drug testing is that it provides no information on how much drug has been taken. However, for illicit drugs or non-prescribed drugs, this issue really doesn’t come into play it’s more a matter of determining whether they’re in the patient’s system or not. But providers are also concerned that their patients may be taking only some of their prescribed pain medication; they may be taking only one pill of their prescribed medication each morning in order to pass their urine drug test and then selling the rest. Because there is no linear relationship between what’s detected in the urine and how much drug was actually ingested, as long as the drug shows up in their urine, that patient is going to appear compliant. If we want to know how much drug was taken, we have to go back to pharmacokinetics and look at steady-state blood levels.

As a provider, if your main concern is illicit drug use or non-prescribed drug use, you’re going to use urine testing because it gives you that extended window of detection to identify those things that should not be there. If your major concern is to determine how much prescribed medication the patient is actually taking, to ensure they’re not taking too little or overmedicating, that’s when you’re going to use blood testing.

On an initial visit, urine is going to be your best friend. However, if you start that patient on a prescribed controlled substance and their urine tests continually come back positive for the correct drug or the correct metabolite, but you have suspicions about how they’re actually taking it, then further down the line you may consider a blood draw just to ensure that they’re actually taking the medication as you’re prescribing it. We’re never going to replace one test with the other, but used together they can be very useful because blood picks up where urine leaves off.

"We’re never going to replace one test with the other, but used together they can be very useful because blood picks up where urine leaves off."

What should clinicians keep in mind when it comes to patient selection for ongoing monitoring? Should testing be used with all patients who are prescribed a controlled substance, or only with high-risk patients?

This topic comes up at a lot of the national meetings. There is no one standard of care right now; there is no one guideline that must be followed when it comes to frequency of testing. But one of the trends that we’re seeing is this idea of risk stratification. I believe in risk stratification. I believe that patients who have been compliant since their initial visit and given the physician no reason to doubt them as a compliant patient may not be the best candidates to have four urine drug tests a year. They may only require one or two drug tests a year.

If, however, on the initial visit a patient gave the provider reason to be somewhat suspicious of their results, then I think the patient should be classified as low-risk, medium-risk, or high-risk. For some of the high-risk patients, it’s not uncommon to see them being tested three or four times a year. In today’s environment, prescribing a controlled substance is justification enough for an initial drug test. But, in my mind, as a toxicologist, I believe the frequency of testing should be based off of that initial drug screen, which is why many providers who are initiating urine drug testing are starting the process off with a urine baseline test on every patient that has been prescribed a controlled substance. By doing a baseline test, you get an overall picture of what’s going on in the practice, with data on every single patient prescribed a controlled substance. If a compliant result matches up with a compliant history for a certain patient, they may not have another drug test until six months later or the following year. Whereas a patient with a history of addiction or abuse, or with a family history, who also returns a concerning urine drug test may certainly go into the high-risk category and be drug tested the following quarter, the following visit, the following refill, or however it is determined in that specific practice.

Does regular testing create an atmosphere of mistrust between patients and their providers, or is that concern overhyped?

I have a lot of conversations with providers about that, especially with family physicians in rural areas of America. Many of these providers know their patients and their families better than anybody. They’ve often known them for a long time, and they’re a little unnerved by the idea of starting to drug test their patients out of the blue, because I think for many patients a urine test is associated with the idea that “you’re trying to catch me doing something I shouldn’t be or you suspect that I’m doing something I shouldn’t be.”

"Many of them are taking the following approach when explaining to patients why they are testing them. They say, “The state is requiring that I do this to keep my license. I need to do this to protect you. I need to do this to make sure that you don’t have anything in your system that’s going to interact with what I’m prescribing, and we need to make sure that you’re metabolizing and excreting these drugs accordingly."

As I talk to more and more providers about this, I find that many of them are taking the following approach when explaining to patients why they are testing them. They say, “The state is requiring that I do this to keep my license. I need to do this to protect you. I need to do this to make sure that you don’t have anything in your system that’s going to interact with what I’m prescribing, and we need to make sure that you’re metabolizing and excreting these drugs accordingly.” Regardless, many patients are going to be uneasy about a urine drug test and that may have the potential to generate some discomfort or tension between the provider and the patient. Providers need to get past that, because as more and more of them begin to do urine testing, they’re finding that some of the patients whom they would never have suspected of being involved in some of these behaviors in fact are, and have been for quite some time.

In the past, when providers were mainly concerned about patients using illicit drugs, there were clinical signs that providers were trained to recognize that may indicate drug abuse or drug dependency. Those still stand, but the problem we’re facing today is that providers may be dealing with patients who are not using these illicit drugs at all. They’re instead obtaining prescription medications and diverting them on the street for money. So how are providers going to identify that in a patient who has no clinical signs of abuse or addiction? We’re dealing with a whole other aspect of aberrant behaviors, and because of that I think we need to look beyond the trust issue and realize that testing protects not only the provider but also the patient.

Urine drug testing and blood testing are useful in identifying aberrant behaviors, but do they promote treatment adherence?

The biggest issue when it comes to this is that until this tool is used in a similar manner across the board, it’s very hard to evaluate patient outcomes. I read an article recently that talked about the fact that the data supporting improved patient outcomes through testing wasn’t that strong. But, in my mind, until it’s used in a uniform manner, we can’t evaluate that.

I’ve talked to providers who dismiss patients on any aberrant urine drug test result. I’ve also talked to providers that give patients three strikes before they’re out. It’s hard to look at how testing affects adherence within a practice when we don’t really know how it’s being interpreted and implemented. In some of the studies that AIT has done, we’ve seen big decreases in illicit drug use rates in practices over 12 months. We’ve published data on the decreased rates of illicit drug use and the decreased rates of noncompliant drug use. I’m a strong advocate for testing increasing adherence, but until testing is used in a uniform manner across the country, it’s going to be very hard to evaluate that with real data.

You mentioned that interpreting testing results correctly and applying them in a clinical setting can be a challenge, especially for non-pain specialists. Does AIT offer tools and resources that can help in that area?

One of the major focuses at AIT is learning how testing is being used in practice and making sure that our clients understand the information they’re receiving from us. Our biggest fear is that one of our testing products generates a result that is misunderstood by the provider, leading to an incorrect clinical decision for which the patient pays the price.

In order to provide better information to our clients without increasing the amount of time they invest on interpretation, we developed AIT Pathways, which provides clinicians with different models of implementing urine drug testing while ensuring the testing is specific to their patient population. One of the major components of AIT Pathways is the urine baseline study. With this model, we take a subset of the client’s patient population and do a single urine drug test, then provide them with a comprehensive overall summary, along with an individual interpretation for each patient result. Rather than leaving the provider to try to decipher the individual toxicology reports and determine what each result indicates, AIT provides the practice with a spreadsheet that indicates what was found in each patient’s system, what wasn’t found, whether they are compliant with their prescribed medications, etc. This gives the provider important information for determining the next course of treatment for that patient.

The urine baselines are the cornerstone of AIT Pathways, which incorporates a three-part model. The second part is what we refer to as GuideMed, which allows providers to identify best practices and protocols for compliance monitoring. Every practice that I visit and every provider I talk to has a different view on how compliance monitoring would best fit their practice. We want to make sure that when we implement this testing it is to the advantage of the provider and the patient. GuideMed allows us to determine things like “Does your state have an electronic script monitoring program?” If so, we’re going to use that as an initial screen for new patients. With GuideMed, we can explain to the doctor when and why he or she may want to do an initial urine drug screen and move through the process into blood testing basically build a flowchart so providers can understand how they should be doing this type of testing based on individual patients. By breaking it down, GuideMed allows these providers to understand exactly why and when they would look at doing each individual toxicology test. We also share with the provider information on what the individual results mean and how to best stratify risk with individual patients and classify them into risk categories.

With AIT Pathways, we would first use GuideMed to evaluate the testing protocols that are going to work best for you and to stratify patients into risk categories. Following that, we would use the Patient Adherence Tool, which is a customizable scheduling tool that alerts the provider when a patient is scheduled for their next urine or blood test. It schedules everything in an automated fashion. Now, that can obviously be modified if the provider determines down the track that they want to include an additional random urine drug screen based on the patient’s behavior. This is a customizable tool that takes all of the guess work out of who to test.

It goes back to the most common questions I get from providers: What should I be doing? How much is too much testing? How little is too little? Who should I be testing? How do I stratify risk without verging on profiling? With AIT Pathways, providers can justify why patients are being tested and how many times a year they’re being tested.

Can AIT Pathways be used to provide a “big picture” of a practice’s compliance program for practices that are interested in performing quality assessment?

Absolutely. It’s easy to pull data on your practice based on the noncompliance rates. It can tell you how many patients were noncompliant with their prescription regimen and why they were noncompliant. It provides statistical feedback on your compliance rate. We have a lot of clients who use that to paint a picture of success. One way to do that is to evaluate compliance based off the initial urine baseline and then evaluate compliance 12 months later. That comes back to the question you asked earlier about whether testing improves patient adherence. I think the best way to evaluate that is to look at your practice and do 12 months worth of testing, looking at the statistical data along the way. We can provide statistical measures comparing your practice’s compliance rates versus every other practice in the state. We can also provide you with statistical compliance rates based on your practice compared to other practices in the country. Obviously, it’s hard to compare two practices of different specialties, but it still is very important information.

Joshua Gunn, PhD, is a toxicologist and Manager of Scientific Education for AIT Laboratories.