Clinician Response to Aberrant Urine Drug Test Results of Patients Prescribed Opioid Therapy for Chronic Pain

Abstract

Objective: Urine drug testing (UDT) is recommended for patients who are prescribed opioid medications, but little is known about the various strategies clinicians use to respond to aberrant UDT results. We sought to examine changes in opioid prescribing and implementation of other risk reduction activities following an aberrant UDT. Methods: In a national cohort of VA patients with new initiations of opioid therapy through 2013, we identified a random sample of 100 patients who had aberrant positive UDTs (results positive for non-prescribed/illicit substance), 100 who had aberrant negative UDTs (results negative for prescribed opioid), and 100 who had expected UDT results. We examined medical record data for opioid prescribing changes and risk reduction strategies in the 12 months following UDT. Results: Following an aberrant UDT, 17.5% of clinicians documented planning to discontinue or change the opioid dose and 52.5% initiated another strategy to reduce opioid-related risk. In multivariate analyses, variables associated with a planned change in opioid prescription status were having an aberrant positive UDT (OR=30.77, 95% CI=5.92–160.10) and higher prescription opioid dose (OR=1.01, 95% CI=1.01–1.02). The only variable associated with implementation of other risk reduction activities was having an aberrant positive UDT (OR=0.29, 95% CI=0.16–0.55). Discussion: The majority of clinicians enacted some type of opioid prescribing or other change to reduce risk following an aberrant UDT, and the action depended on whether the result was an aberrant positive or aberrant negative UDT. Experimental studies are needed to develop and test strategies for managing aberrant UDT results.

Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results

“…Nonetheless, the decision to change opioid prescribing practices is complex and hinges upon multiple patient variables, even among aberrant UDT results. 39,47 In our study, 85% of aberrant cases and 100% of discordant interpretations had a refill at the subsequent follow-up appointment. Without additional information, we cannot definitively conclude whether these refills were truly inappropriate.…”

Contextual Factors and Adoption of Strategies Related to Opioid Prescribing Practices in Healthcare Settings: Cross-Sectional Study

“…Another possible explanation might be that physicians felt more comfortable with prescribing more opioid prescriptions with drug testing. It should also be noted that while there have been studies examining rates of using drug testing (Turner et al, 2014) and effects of aberrant drug test results on clinical decisions (e.g., whether to continue, change, or discontinue opioid therapy) (Morasco et al, 2019), limited studies have examined the effects of having drug testing itself on opioid prescribing behaviors. Further work is required to establish the relationship, and particularly causality, between the implemented strategies to support the safe use of opioid therapy and physicians' opioid prescribing practices.…”

Priming primary care providers to engage in evidence-based discussions about cannabis with patients

“…In practice, a provider who offers medical cannabis certification is likely to be someone other than the opioid prescriber, giving rise to potential conflicts in treatment philosophies. The opioid prescriber’s assessment of potential benefit and risk may differ from the cannabis certifier and the prescribers sometimes abruptly discontinue opioid therapy with evidence of cannabis use, whether certified or not [73, 74]. Finally, issues of provider liability may become complex if a patient who has both an opioid prescriber and a medical cannabis certifier were to overdose.…”