Potential for Misuse
Potential hazards of using opioids to treat chronic pain include their misuse, abuse, or diversion for recreation or profit. Opioid misuse increases the risks of addiction, overdose, and death. These risks increase for patients with personal or family histories of drug abuse or dependence and patients in communities with limited job opportunities.
A patient's history of substance misuse doesn't absolutely preclude the use of opioid therapy, but management of that patient should include increased monitoring and consultation, and possible discontinuation with appropriate specialists.
Clinicians should screen patients when first considering use of chronic opioid therapy and periodically during active treatment. Screening surveys may be helpful to a clinician in determining the risk of aberrant drug behaviors and guiding the frequency of monitoring. Screening surveys could be incorporated into the triage/nurse screening process prior to seeing the clinician. Screening can include surveys including but not limited to:
- Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R)
- Brief Risk Interview (BRI)
- Current Opioid Misuse Measure (COMM)
- Opioid Risk Tool (ORT)
- Biological screens, such as urine drug screens
- Assessment of drug effects during examinations
- General alertness to other physical, emotional, and social indicators
- Prescription Drug Monitoring Program Results Reports
Urine Drug Screens
Urine drug testing (UDT) should be used as a therapeutic tool and screens can be useful for monitoring adherence to therapy and for detecting the presence of other illicit or non-prescribed controlled substances that may point to a need for increased surveillance, consultation, and possible discontinuation of current opioid treatment. Laboratory tests are also necessary to verify the presence of the prescribed opioid medication at levels that are consistent with dose and frequency in order to detect potential aberrant behavior such as diversion. Providers that are involved in urine drug testing should determine the questions the tests are intended to answer prior to specimen collection. A review of the test results and a prompt, meaningful response to findings are necessary to fully integrate urine drug testing into managing chronic pain.
The clinician's choice of a urine drug screen needs to be consistent with the patient's pain therapy. There are not any one-size-fits-all screens covering the entire range of opioids. The urine drug screen also needs to be consistent with drug use patterns in the community. Legal and illegal drug use patterns vary between communities. Immunoassay and gas chromatography/mass spectrometry (GC/MS) urine tests measure metabolites (for the most part) that presume to indicate the use of controlled substances. Immunoassays are usually conducted in office and serve as presumptive testing. An appropriate follow-up to a positive presumptive test may include a discussion with the laboratory for assistance in interpreting the test results. A positive result from an immunoassay may indicate the need for follow-up testing with the more accurate GC/MS (usually at an outside laboratory). False positive results in urine testing remain a problem, even with GC/MS tests used for confirmation. And, not all GC/MS tests are created equal; the quality of GC/MS tests vary greatly between laboratories. Special lab test orders are typically required for the detection of methadone, buprenorphine, tramadol, and gabapentinoids.
Sample Specimen Integrity Testing and Result Interpretation
|Urine Specimen Integrity Test||Previous Result||Previous Interpretation||Revised Result||Revised Interpretation|
|Creatinine (mg/dL)||< 2.0||Specimen unusually dilute, suspect specimen dilution/substitution||< 2.0||Suspect specimen substitution|
|Creatinine (mg/dL)||2.0 - 19.9||Specimen unusually dilute||2.0 - 19.9||Specimen dilute|
|Creatinine (mg/dL)||20 - 200||No comment||20 - 300||Specimen normal|
|Creatinine (mg/dL)||> 200||Specimen unusually concentrated||> 300||Specimen concentrated|
|pH||< 3||Specimen unsatisfactory, abnormally low pH, suspect specimen adulteration||< 3||Specimen unsatisfactory, abnormally low pH, suspect specimen adulteration|
|pH||3 - 11||Specimen within normal limits||3 - 11||Specimen within normal limits|
|pH||> 11||Specimen unsatisfactory, abnormally high pH, suspect specimen adulteration||> 11||Specimen unsatisfactory, abnormally high pH, suspect specimen adulteration|
|General Oxidants||Negative||Specimen within normal limits||Negative||Specimen within normal limits|
|General Oxidants||Positive||Specimen unsatisfactory, presence of an oxidant detected, suspect specimen adulteration||Positive||Specimen unsatisfactory, presence of an oxidant detected, suspect specimen adulteration|
|Cannabinoids||Non-Steroidal anti-inflammatory drugs, dronabinol, pantoprazole|
|Opioids||Poppy seeds, chlorpromazine, rifampin, dextromethorphan, quinine|
|Amphetamines||Ephedrine, pseudoephedrine, phenylephrine, methylphenidate, trazodone, bupropion, desipramine, amantadine, ranitidine, phenylpropanolamine, Vicks Vapor Spray|
|PCP||Chlorpromazine, thioridazine, meperidine, dextromethorphan, diphenhydramine, doxylamine|
|Benzodiazepine||Oxaprozin, some herbal agents|
|Alcohol (EtOH)||Asthma inhalers (sometimes)|
Gas chromatography should confirm all positives; screening detects a presence or absence, not the concentration. Drug tests are not quantitative.
Source: Manchikanti L, et al. Protocol for accuracy of point of care (POC) or in-office urine drug testing (Immunoassay) in chronic pain patients: A prospective analysis of immunoassay and liquid chromatography tandem mass spectometry (LC/MS/MS). Pain Physician 2010; 13:E1-E22 (49).
- ASSIST (Alcohol, Smoking, Substance Involvement Screening Test)
- ‘4Ps’ (Parents, Partners, Past, and Pregnancy) CRAFFT
- DAST-10 (Drug Abuse Screening Test)
Fishman, MD, Scott M. Responsible Opioid Prescribing: A Physician's Guide. Washington, DC: Waterford Life Sciences, 2007. pp. 21-25.
Manchikanti, MD, Laxmaiah, et al. "Protocol for Accuracy of Point of Care (POC) or In-Office Urine Drug Testing (Immunoassay) in Chronic Pain Patients: A Prospective Analysis of Immunoassay and Liquid Chromatography Tandem Mass Spectometry (LC/MS/MS) ." [PDF - 500 KB] Pain Physician 13 (2010): E1-E22.
Jones, T., Moore, T. (2013). Preliminary Data on a New Opioid Risk Assessment Measure: The Brief Risk Interview. Journal of Opioid Management. 9 (1), 20-27.
Christo, P; Manchikanti, L; et al. "Urine Drug Testing in Chronic Pain." Pain Physician. (2011), 14: 123-143.
Melanson (etal). "Optimizing Urine Drug Testing for Monitoring Medication Compliance in Pain Management." Pain Med. (2013), Jul 30 (epub ahead of print).
Milone, M. "Laboratory Testing for Prescription Opioids." J Med Toxicol. (2012) 8:408-16. (Urine Drug Testing in Primary Care, accessed September 18, 2013)
Appropriate Use of Drug Testing in Clinical Addiction Medicine [PDF - 1.3 MB] — ASAM Consensus Statement, 2017.
Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32 — Substance Abuse and Mental Health Services Administration, 2012.