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INTRODUCTION

 

Today, drug testing is an important part of common patient care.


Drug testing can facilitate good medical care and help to solve complex patient management problems. The value of clinical drug testing in the general medical populations not showing an elevated risk of substance use may be questioned because of the costs incurred by the patient, the practitioner, and the health care system as a whole.

However, given the high prevalence of substance use disorders, including among medical patients, drug testing can facilitate improved patient outcomes. When applied thoughtfully to any patient population, especially those at high risk of substance use disorders, drug test results can lead to a useful clinical discussion between patients and their physicians that would otherwise not occur.

Drug testing, like testing for blood sugar and blood pressure, provides clinically useful information that can inform and improve patient care and provides an opportunity for health education by the physician or other healthcare provider.

Drug testing can be successfully integrated into many aspects of health care. Physicians are in an excellent position to work with patients to identify and to intervene with problematic drug and alcohol use, and to manage patient care during and after treatment, parallel to the management of patients with hypertension and diabetes.

Currently, drug testing is frequently underutilized in many health care settings, including pain management and primary care, even when controlled substances are prescribed.

Drug testing can be used in both hospital and outpatient settings, including pain medicine, palliative medicine, psychiatry, obstetrics, geriatrics, primary care, etc. While this is not an exhaustive list, the following discussion of drug testing provides a good introduction to drug testing in general health care and in specific medical settings.

The use of drug testing in pain management is an area of medicine which is undergoing a very important revolution, largely because of the growing recognition of the importance of opioid misuse, a problem that has reached an epidemic level. The field of pain management is now wrestling with the challenges of promoting effective relief of pain while identifying substance misuse and diversion in this high-risk patient population.

SPECIALTIES

 

PAIN MEDICINE

Long-term opioid therapy for the management of chronic non-cancer pain (CNCP) has gained widespread clinical acceptance over the past two decades. In recent years however, many unintended consequences have become apparent. As prescriptions for opioids have dramatically increased, opioid-related treatment episodes, emergency room visits, and drug-related deaths have increased in parallel.

There continues to be a role for long-term opioid therapy in selected patients with CNCP, but it is clear that careful, ongoing monitoring for opioid-related problems is an essential component of that care.

Monitoring techniques include speaking with patients about their medication use and their lives, investigating and discerning the meaning of aberrant drug-related behaviors, querying state prescription drug monitoring program (PDMP) databases at the onset of opioid prescribing and for the duration of a plan of care for chronic non-cancer pain, and performing drug testing.

Patients are sometimes untruthful about their drug use and behavioral monitoring can be of limited value in identifying patients who misuse drugs. The clinician’s “hunch” and the identification of aberrant behaviors on the part of patients have been shown to correlate poorly with the actual presence of addiction in a given patient. Thus, there is no substitute for drug testing combined with good clinical judgment.

Selected evidence indicates that drug testing in pain management may improve patient adherence. Finally, drug testing in pain medicine is recommended in several clinical guidelines, including those of the American Pain Society, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the Federation of State Medical Boards, among others.

Drug testing comprises a number of sophisticated analytic techniques and its ordering and interpretation can, at times, be complex. The ethical application of drug testing imposes an obligation on the physician to order tests, interpret the results, and respond clinically with requisite knowledge and skill.

The use of drug testing in pain management has increased exponentially over the past decade. This fact conceals three important realities. First, drug testing remains underutilized in pain management. A recent survey of physician members of the American Pain Society, the American Academy of Pain Medicine, and the American Society of Regional Anesthesia and Pain Medicine found that only 59% of respondents order random urine drug testing. Second, drug testing is highly skewed by medical specialty.

Medicare data shows that anesthesiologists (who comprise 74% of pain specialists) ordered nearly as many drug tests in 2009 (636,880) as family practice physicians (258,132), internal medicine physicians (241,431), neurologists (128,713), and general practitioners (70,031) combined.

A recently published study of a large primary care health system found that only 8% of patients receiving long-term opioid therapy – and only 24% of the highest risk patients – were evaluated via urine drug testing. Third, evidence indicates that, regardless of specialty, many physicians who employ drug testing are not proficient in interpreting test results.

PSYCHIATRY

Psychiatrists and primary care physicians managing psychiatric problems can successfully incorporate drug testing into their routine treatment plans. For example, psychostimulants prescribed for attention deficit/hyperactivity disorder (ADHD) or depression, and benzodiazepines, prescribed for anxiety disorders and other conditions, are subject to misuse, addiction, and diversion.

Physicians and other professionals with prescribing authority too often initiate authorizations for these classes of drugs without conducting even cursory screening for risk of misuse. This failure of vigilance contributes to the widespread misuse and diversion of these drugs.

Patients provided with prescriptions for controlled substances including stimulants, sedative-hypnotics including benzodiazepines, and opioids are at risk of using illicit drugs and/or alcohol along with their prescription medications, putting their health and safety at risk as well as posing a risk of diversion. Just as informed consent between the prescriber and the patient is a useful component of high-quality health care when opioids are prescribed, so is it a component of high-quality health care when psychostimulants or benzodiazepines are prescribed.

This approach incorporates the concept of “universal precautions” to minimize the risk of misuse of prescription medications. Written treatment agreements signed by both the prescriber and the patient used in mental health treatment settings, as they are in pain management settings, call for wider use random drug tests.

Adolescents and young adults, who are more prone to poor judgment and poor impulse control, are at higher risk for the development of addiction when they do use drugs of abuse. The highest rates of substance use disorders occur in the late teens and the twenties. In addition, there is a high level of psychiatric and addiction comorbidity in these age groups with patients often minimizing or denying drug use to their physicians.

For this reason, it is appropriate to consider periodic random drug testing for all psychiatric patients, and especially young patients and those with a history of substance use disorders, particularly when they have been prescribed psychostimulants or benzodiazepines.

This should become part of the standard treatment planning of private psychiatric practices, community health (and mental health) centers, and other primary care practices where patients are prescribed psychopharmacological agents with the potential for misuse.

OBSTETRICS/GYNECOLOGY

The incidence of neonatal abstinence syndrome (i.e. opioid withdrawal in the newborn) increased almost 300% from 2000 to 2009. During the same time period, the incidence of pregnant women physically dependent on opioids at the time of delivery increased almost 500%.

In the past three decades, first trimester use of prescription medications has increased more than 60%. The incidence of use of four or more medications during pregnancy has more than tripled.

Illicit drug use during pregnancy may involve the use of prescription drugs or street drugs. In the case of opioids, it is likely that the illicit use began prior to conception.

Obstetric patients underreport their use of medications, drugs of abuse, and alcohol. In a study of electronic medical records versus self-reporting, 50% of patients did not report their use of opioids and 50% of patients did not report their use of antidepressants. However, reliability was good for the use of diabetes, thyroid, and asthma medications. Sociodemographic and reproductive health characteristics were not predictive of medication use. Because of the underreporting of opioids and benzodiazepines, it is often helpful for the obstetrician to use drug testing to complement patient history.

The American College of Obstetricians and Gynecologists (AGOC) and ASAM have jointly recommended that all obstetrical patients be routinely asked about their use of alcohol and other drugs. Screening may include the use of urine drug tests when patient consent is obtained and the patient understands the purpose of the test and how the results will be used, including any mandatory state reporting requirements. Although ACOG states that laboratory drug testing “is not appropriate for routine well-women care,” the organization recommends the use of drug testing when substance use is suspected.

It is of particular importance to identify among obstetric patients the use of alcohol, and specific opioids and benzodiazepines. POC urine testing has limitations because it will not identify alcohol or certain opioid(s) and/or their metabolites.

While benzodiazepines are generally detected by POC immunoassay, not all benzodiazepines are equally detected by all reagents. Since polypharmacy is common, especially in more complicated pregnancies, it may be clinically useful to identify the specific drug being used and to extend the range of drugs being identified by using a laboratory–based test using LC-MS/MS.

With regard to screenings, the use of laboratory-based immunoassay testing, as opposed to POC testing, may somewhat reduce the likelihood of false positive or false negative test results, while providing greater specificity in drug identification. These benefits may be offset by the extra cost and the delayed timeframe for the clinician receiving the test result.

Patient-centered drug testing enhances physician awareness of medication/drug use and possible misuse, and it provides the physician an opportunity to educate and motivate behavioral change. This is an opportunity for collaboration and building a trusting patient-provider relationship.

Two studies in the Kaiser Health System in 2003 and 2008 encompassed nearly 50,000 obstetrical patients. Women were screened as possible substance users by both patient questionnaires and urine drug tests. Patients who screened positive, with positive responses to questionnaires and positive drug test results, were placed in an early intervention program.

These patients had virtually the same outcomes as the control group, who screened negative for substance use, with regard to neonates requiring assisted ventilation, low birth weight, preterm delivery, placental abruption, and intrauterine fetal demise.

Patients who screened positive for drug use and did not participate in any treatment had risk outcome ratios 2-16 times higher than the controls. The worst results were with intrauterine fetal demise. This study suggests that, in at least this complicated population of obstetrical patients, drug testing and patients’ self-reporting can assist in effective resource allocation to improve maternal and fetal outcomes.

DRUG TESTING IN MEDICAL SPECIALTIES

 

Best practices in obstetrics require utilization of a comprehensive substance use assessment, including patient-centered drug testing. Sadly, the obstetrical population is no less likely to suffer from substance use disorders than the general population. Recognizing this reality, drug testing is an underutilized tool in the optimum care and management of this important and vulnerable patient population.

PRIMARY CARE

 

The use of drug testing in primary care has been addressed in a Technical Assistance Publication (TAP) by the federal Center for Substance Abuse Treatment (CSAT). There are several other guidelines developed by medical organizations and state medical societies including the Johns Hopkins University School of Medicine’s continuing medical education monograph on urine drug testing in clinical practice for physicians.

Screening for unhealthy levels of alcohol use and non-prescribed drug use through brief questions and motivational interviewing has been shown to be effective in identifying and helping patients with problems. SBIRT (Screening, Brief Intervention, and Referral to Treatment) is a key feature of the Patient Protection and Affordable Care Act (PPACA). Physicians are encouraged to ask all adolescent and adult patients about their use of alcohol and drugs.

During the screening process, physicians ask patients if, in the past year they have ever consumed five or more standard drinks in a single sitting; if they have used any illegal drugs; if they have used prescription drugs without a valid prescription; and if they have used a prescription drug in ways not consistent with the recommendations of the prescribing physician. A "yes" answer to any element of this screen leads to further evaluation, which may include a test for alcohol and other drugs.

Drug testing is especially important in primary care when dealing with patients who are at high risk of substance misuse or addiction. Recognizing that substance use is widespread, there are few if any unaffected patient populations.

Nevertheless, it is wise to focus initially on the patient populations most at risk for substance misuse, including patients with a personal history of use, patients who have been treated for complications of substance use, including accidents, overdoses and infectious diseases, and patients with family histories of addiction.

Drug testing among high-risk populations includes routine testing to identify patients who are drug users, to assist in assessment of potential substance use disorders (SUDs), and to monitor recovery in patients with histories of SUDs.

When patients are diagnosed with SUDs it is essential that the diagnosis not be a reason to withhold medical treatment in primary care; rather, it is an opportunity to intensify medical care and offer interventions. SUDs are commonly lifelong problems that require medical monitoring as part of health promotion and to identify relapses. SUDs are often treatable in primary care settings.

For those patients, whose SUDs cannot be managed successfully in these settings, referral to a specialized addiction clinician is indicated. Even then, however, it is important for primary care providers to remain involved in the ongoing care and monitoring of their patients, especially after they return from a specialty care setting to the care of the primary care provider.

The emergence of accountable care organizations (ACOs) and other payment reforms, and the emergence of medical homes and other primary care delivery system reforms, underscore the importance of not only the recognition of SUDs as major public health problems but also their long-term management within the medical context in both private sector and public sector settings.

Drug testing should become a routine part of the ongoing testing process for SUDs in all primary care settings so as to discourage unauthorized drug use and to detect such use when it occurs, in order to allow for early intervention. The preventive and early diagnostic functions of drug testing are at the core of its wider use in health care settings.

Drug testing is important in primary care settings when physicians need to know about drug use prior to starting a medication or treatment in which drug use could be a critical determinant of outcome. For example, some neurosurgeons test patients for tobacco use before spinal surgery and may refuse surgery if the patient is positive for cotinine, and some orthopedic surgeons have imposed similar requirements on their patients before joint surgery.

Additionally, when considering prescribing controlled substances, it is helpful to determine ongoing drug use. In such cases, a patient may refuse the drug test, but that may decrease the treatment options and the clinician may decide to withhold the prescribing of the controlled substance. The most important reason for such a protocol is safety.

A drug-addicted person may seek additional drugs through prescription, which would increase their risk of overdose. Testing is also important in older patients who may have sleep apnea, chronic obstructive pulmonary disease, or other medical conditions that could make overdose or other adverse effects of opioid use more likely.

Drug testing can also prevent unnecessary prescribing in primary care. Drug use may cause the symptoms patients are seeking to treat. For example, students seeking stimulants to treat attention deficit hyperactivity disorder (ADHD), without symptoms of the disorder present in childhood may exhibit ADHD symptoms as adults after marijuana or other drug use.

Proper initial treatment of such a patient would involve discontinuing stimulant use to determine if the ADHD symptoms resolve. Similarly, some patients seek benzodiazepines from a physician because of anxiety and insomnia, but the actual cause of the symptoms might be stimulant misuse.

Unfortunately, physicians who do not use drug testing in practice may prescribe multiple controlled substances to patients whose condition is caused by illegal drug use. New prescriptions may only make the problems worse. Much of this behavior may be preventable by routine drug testing in primary care.

Drug testing is appropriate in monitoring patients on prescribed controlled substances. An example of a safety concern is prescribing oxycodone to a patient who begins to use alprazolam or methadone purchased on the street. Drug testing can also help detect patients who are not taking their medications at all.

Although such drug tests are voluntary, it is acceptable medical practice that they be required if the physician is going to prescribe medications. Similarly, a physician would not continue to prescribe a blood thinner such as warfarin to a patient who refused a prothrombin time test.

Similarly, an oncologist would not continue chemotherapy for a patient who refuses white blood cell counts or liver function tests. Drug testing is voluntary but is linked to voluntary treatment, be it use of warfarin to treat blood clots, chemotherapy to treat cancer, long-term opioids to treat pain, or amphetamine to treat ADHD.

In spite of the difficulties in doing drug testing in primary care, there are many surprise results that can impact treatment. The key to success is accuracy, confirmation, and a positive, therapeutic attitude on the part of the physician and staff.

CITATIONS

 

Drug Testing in Medical Specialties

i. American Academy of Pain Medicine http://www.painmed.org/
ii. American Society for Pain Management Nursing http://www.aspmn.org/Pages/default.aspx
iii. Academy of Integrative Pain Management http://www.aapainmanage.org/
iv. American Pain Society http://www.americanpainsociety.org
v. Why the new NIH guidelines for psychiatric drug testing worry me https://blogs.scientificamerican.com/the-curious-wavefunction/why-the-new-nih-guidelines-for-psychiatric-drug-testing-worry-me/
vi. American Society of Addiction Medicine: “Public Policy Statement On Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings” https://www.asam.org/docs/default-source/public-policy-statements/1drug-testing---clinical-10-10.pdf
vii. American College of Obstetricians and Gynecologists: Committee Opinion, Number 633, June 2015 https://www.acog.org/-/media/Committee-Opinions/Committee-on-Ethics/co633.pdf?dmc=1
viii. American College of Obstetricians and Gynecologists: Committee Opinion, Number 524, May 2012 -Opioid Abuse, Dependence, and Addiction in Pregnancy https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy
ix. American College of Obstetricians and Gynecologists: Committee Opinion, Number 473, January 2011 -Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician-Gynecologist https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Substance-Abuse-Reporting-and-Pregnancy-The-Role-of-the-Obstetrician-Gynecologist
x. Substance Abuse and Mental Health Services Administration – Drug Testing https://www.samhsa.gov/workplace/drug-testing
xi. American Society of Addiction Medicine – The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine https://www.asam.org/quality-practice/guidelines-and-consensus-documents/drug-testing

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