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Review of the Current State of Urine Drug Testing in Chronic Pain: Still Effective as a Clinical Tool and Curbing Abuse, or an Arcane Test?

  • Alternative Treatments for Pain Medicine (M Jones, Section Editor)
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Abstract

Purpose of Review

Therapeutic use, misuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain remain a major concern for physicians, the government, payers, and patients. The challenge remains finding effective diagnostic tools that can be clinically validated to eliminate or substantially reduce the abuse of controlled prescription drugs, while still assuring the proper treatment of those patients in pain. Urine drug testing still remains an important means of adherence monitoring, but questions arise as to its relevance and effectiveness. This review examines the role of UDT, determines its utility in current clinical practice, and investigates its relevance in current chronic pain management.

Recent Findings

A review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literature was searched from year 2000 to present examining the relevance and role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. There are only a limited number of reviews and investigations on UDT, despite the fact that clinicians who prescribe controlled medications for chronic states commonly are expected to utilize UDT. Therefore, despite highly prevalent use, there is a limited publication base from which to draw in this present study.

Summary

Regardless of experience or training background, physicians and healthcare providers can much more adequately assess opioid therapy with the aid of UDT, which often requires confirmatory testing by a laboratory for clinical and therapeutic prescribing decisions. It has become a strongly recommended aspect of pain care with controlled substances locally, regionally, and nationally. Incorporating UDT for all patients in whom chronic opioid therapy is undertaken is consistent with state and national guidelines and best practice strategies. Practice standards vary as to the frequency of UDT locally, regionally, and nationally, however.

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Data Availability

Available upon request from the corresponding author.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • Volkow N. Prescription drug abuse—December 2011: a research update from the national institute on drugs abuse. Topics in Brief. 2011. This is a comprehensive research update from the National Institute on Drugs Abuse.

  2. Administration SAaMHS. Drug Abuse Warning Network, 2010: area profiles of drug-related mortality HHA Publication No. (SMA) 12-4699, DAWN Series D-36. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2012.

  3. Wunsch M, Nakamoto K, Behonick G, Massello W. Opioid deaths in rural Virginia: a description of the high prevalence of accidental fatalities involving prescribed medications. Am J Addict. 2009;18:5–14.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Standridge J, Adams S, Zotos A. Urine drug screening: a valuable office procedure. Am Fam Physician. 2010;81:635–40.

    PubMed  Google Scholar 

  5. Peppin JF, Passik SD, Couto JE, Fine PG, Christo PJ, Argoff C, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Med. 2012;13(7):886–96.

    Article  PubMed  Google Scholar 

  6. Rudd R, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445–52.

    Article  PubMed  Google Scholar 

  7. Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Gourlay D, Heit H, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107–12.

    Article  PubMed  Google Scholar 

  9. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep. 2016;65:1–49.

    Article  PubMed  Google Scholar 

  10. Pesce A, West C, Egan City K, Strickland J. Interpretation of urine drug testing in pain patients. Pain Med. 2012;13:868–85.

    Article  PubMed  Google Scholar 

  11. Markway E, Baker S. A review of the methods, interpretation, and limitations of the urine drug screen. Orthopedics. 2011;34:877–81.

    Article  PubMed  Google Scholar 

  12. Knezevic N, Khan O, Beiranvand A, Candido K. Repeated quantitative urine toxicology analysis may improve chronic pain patient compliance with opioid therapy. Pain Physician. 2017;20:S135–S45.

    Article  PubMed  Google Scholar 

  13. Jannetto P, Bratanow N, Clark W, et al. Executive summary: American Association of Clinical Chemistry Laboratory Medicine Practice Guideline–using clinical laboratory tests to monitor drug therapy in pain management patients. J Appl Lab Med. 2018;2:489–526.

    Article  PubMed  Google Scholar 

  14. Manchikanti L, Malla Y, Wargo B, Fellows B. Comparative evaluation of the accuracy of immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing (UDT) opioids and illicit drugs in chronic pain patients. Pain Physician. 2011;14:175–87.

    Article  PubMed  Google Scholar 

  15. Manchikanti L, Malla Y, Wargo B, Fellows B. Comparative evaluation of the accuracy of benzodiazepine testing in chronic pain patients utilizing immunoassay with liquid chromatography tandem mass spectrometry (LC/MS/MS) of urine drug testing. Pain Physician. 2011;14:259–70.

    Article  PubMed  Google Scholar 

  16. Kirsch K, Christo P, Heit H, Steffel K, Passik S. Specimen validity testing in urine drug monitoring of medications and illicit drugs: clinical implications. J Opioid Manag. 2015;11:53–9.

    Google Scholar 

  17. Lynch K. Specimen validity testing: is it “valid” for drug testing in pain management?, J Appl Lab Med. 2018;2:478–80.

  18. •• Ali MM, Dowd WN, Classen T, Mutter R, Novak SP. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health. Addict Behav. 2017;69:65–77 This paper discusses evidence from the National Survey of Druge Use and Health regarding prescription drug monitoring programs.

    Article  PubMed  Google Scholar 

  19. Bao Y, Pan Y, Taylor A, Radakrishnan S, Lu F, Pincus H, et al. Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Aff (Millwood). 2016;35:1045–51.

    Article  Google Scholar 

  20. Patrick S, Fry C, Jones T, Buntin M. Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Aff (Millwood). 2016;35:1324–32.

    Article  Google Scholar 

  21. Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a tenyear perspective. Pain Physician. 2010;13:401–35.

    Article  PubMed  Google Scholar 

  22. Kosten T, George T. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1:13–20.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Passik S, Kirsch K. Opioid therapy in patients with a history of substance abuse. CNS Drug. 2004;18:13–25.

    Article  CAS  Google Scholar 

  24. Passik S, Kirsch K. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Curr Pain Headache Rep. 2004;8:289–94.

    Article  PubMed  Google Scholar 

  25. Kuehn B. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA. 2007;297:249–51.

    CAS  PubMed  Google Scholar 

  26. Victor GA, Walker R, Cole J, Logan TK. Opioid analgesics and heroin: examining drug misuse trends among a sample of drug treatment clients in Kentucky. Int J Drug Policy. 2017;46:1–6.

    Article  PubMed  Google Scholar 

  27. Ford JA, Sacra SA, Yohros A. Neighborhood characteristics and prescription drug misuse among adolescents: the importance of social disorganization and social capital. Int J Drug Policy. 2017;46:47–53.

    Article  PubMed  Google Scholar 

  28. Serdarevic M, Striley CW, Cottler LB. Sex differences in prescription opioid use. Curr Opin Psychiatry. 2017;30:238–46.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Roxburgh A, Darke S, Salmon AM, Dobbins T, Jauncey M. Frequency and severity of non-fatal opioid overdoses among clients attending the Sydney Medically Supervised Injecting Centre. Drug Alcohol Depend. 2017;176:126–32.

    Article  PubMed  Google Scholar 

  30. Kerensky T, Walley AY. Opioid overdose prevention and naloxone rescue kits: what we know and what we don’t know. Addict Sci Clin Pract. 2017;12:4.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Roy É, Arruda N, Leclerc P, Morissette C, Blanchette C, Blouin K, et al. Drug use practices among people who inject drugs in a context of drug market changes: challenges for optimal coverage of harm reduction programs. Int J Drug Policy. 2017;45:18–24.

    Article  PubMed  Google Scholar 

  32. Huhn AS, Dunn KE. Why aren’t physicians prescribing more buprenorphine? J Subst Abus Treat. 2017;78:1–7.

    Article  Google Scholar 

  33. Estreet A, Archibalde P, Tirmazi MT, Goodman S, Cujoe T. Exploring social work student education: the effect of a harm reduction curriculum on student knowledge and attitudes regarding opioid use disorders. Subst Abus. 2017;52:00.

    Google Scholar 

  34. Syvertsen JL, Paquette CE, Pollini RA. Down in the valley: trajectories of injection initiation among young injectors in California’s Central Valley. Int J Drug Policy. 2017;44:41–9.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Meshesha LZ, Pickover AM, Teeters JB, Murphy JG. A longitudinal behavioral economic analysis of non-medical prescription opioid use among college students. Psychol Rec. 2017;67:241–51.

    Article  Google Scholar 

  36. Bellew S, Barrett TW. Loperamide will stop you up but it can also bring you down. Ann Emerg Med. 2017;69:786–91.

    Article  PubMed  Google Scholar 

  37. Compton W, Jones C, Baldwin G. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154–63.

    Article  CAS  PubMed  Google Scholar 

  38. Manchikanti L, Kaye A, Knezevic N, McAnally H, Slavin K, Trescot A, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2017;20:S30S92.

    Google Scholar 

  39. Gourlay D, Heit H. Pain and addiction: managing risk through comprehensive care. J Addict Dis. 27:23–30.

  40. Manchikanti L, Malla Y, Wargo B, Cash K, Pampati V, Damron K, 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.

    Article  PubMed  Google Scholar 

  41. •• Knezevic N, Khan O, Beiranvand A, Candido K. Repeated quantitative urine toxicology analysis may improve chronic pain patient compliance with opioid Therapy. Pain Physician. 2017;20:S135–S45 This analysis suggests that repeated quantitative urine toxicology analysis may improve compliance in patients using chronic opioids.

    Article  PubMed  Google Scholar 

  42. Yee YD, Hughes M, Guo A, Barakat N, Tse S, Ma J, et al. Observation of improved adherence with frequent urine drug testing in patients with pain. J Opioid Manag. 2014;10:111–8.

    Article  PubMed  Google Scholar 

  43. Morasco B, Krebs E, Cavanagh R, Hyde S, Crain A, Dobscha S. Treatment changes following aberrant urine drug test results for patients prescribed chronic opioid therapy. J Opioid Manag. 2015;11:45–51.

    PubMed  Google Scholar 

  44. Christo P, Manchikanti L, Ruan X, Bottros M, Hansen H, Solanki D, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123–43.

    Article  PubMed  Google Scholar 

  45. Butler S, Fernandez K, Benoit C, Budman S, Jamison R. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9:360–72.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Butler S, Budman S, Fernandez K, et al. Development and validation of the current opioid misuse measure. Pain. 2007;130:144–56.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Moore T, Jones T, Browder J, Daffron S, Passik S. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10:1426–33.

    Article  PubMed  Google Scholar 

  48. Hamill-Ruth R, Larriviere K, McMasters M. Addition of objective data to identify risk for medication misuse and abuse: the inconsistency score. Pain Med. 2013;14:1900–7.

    Article  PubMed  Google Scholar 

  49. • Ko M, Woster P, Smith T. (205) Predictors of illicit substance use assessed by urine drug monitoring in patients prescribed opioid medications. The Journal of Pain (2016);17(4):S27. https://doi.org/10.1016/j.jpain.2016.01.108. This review is an excellent manuscript on profiles of drug-related mortality.

  50. Woster P, Ko M, Smith T. Predictors of medication adherence assessed by urine drug monitoring in patients prescribed opioid medications: relationship with opioid dose. J Pain. 2016;17:S27.

    Article  Google Scholar 

  51. Morasco B, Peters D, Krebs E, Kovas A, Hart K, Dobscha S. Predictors of urine drug testing for patients with chronic pain: results from a national cohort of U.S. veterans. Subst Abus. 37:82–7.

  52. Manchikanti R, Manchikanti L, Damron K, Brandon D, McManus C, Cash K. Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician. 2006;9:57–60.

    Article  PubMed  Google Scholar 

  53. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2–guidance. Pain Physician. 2012;15:S67–S116.

    PubMed  Google Scholar 

  54. Nafzinger A, Bertino J. Utility and application of urine drug testing in chronic pain management with opioids. Clin J Pain. 2009;25:73–9.

    Article  Google Scholar 

  55. Reisfield G, Bertholf R, Barking R, Webb F, Wilson G. Urine drug test interpretation: what do physicians know? J Opioid Manag. 2007;3:80–6.

    Article  PubMed  Google Scholar 

  56. Reisfield G, Graham N, Gold M. Urine drug testing is still an invaluable resource for primary care. Ann Intern Med. 2010;153:420 author reply -1.

    Article  PubMed  Google Scholar 

  57. Moeller K, Lee K, Kissack J. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83:66–76.

    Article  CAS  PubMed  Google Scholar 

  58. Reisfield G, Salazar E, Bertholf R. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37:301–14.

    CAS  PubMed  Google Scholar 

  59. Wu AH. Integrity of urine specimens submitted for toxicologic analysis: adulteration, mechanisms of action, and laboratory detection. Forensic Sci Rev. 1998;10:47–65.

    CAS  PubMed  Google Scholar 

  60. Tanda G, Pontieri FE, Di Chiara G. Cannabinoid and heroin activation of mesolimbic dopamine transmission by a common mu1 opioid receptor mechanism. Science. 1997;276(5321):2048–50.

    Article  CAS  PubMed  Google Scholar 

  61. Rodriguez JJ, Mackie K, Pickel VM. Ultrastructural localization of the CB1 cannabinoid receptor in mu-opioid receptor patches of the rat caudate putamen nucleus. J Neurosci. 2001;21(3):823–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Savage SR, Romero-Sandoval A, Schatman M, Wallace M, Fanciullo G, McCarberg B, et al. Cannabis in pain treatment: clinical and research considerations. J Pain. 2016;17(6):654–68.

    Article  PubMed  Google Scholar 

  63. Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manag. 2004;27(3):260–7.

    Article  Google Scholar 

  64. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Damron KS, 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(1):E1–e22.

    Article  PubMed  Google Scholar 

  65. St John A, Price CP. Existing and emerging technologies for point-of-care testing. Clin Biochem Rev. 2014;35(3):155–67.

    PubMed  PubMed Central  Google Scholar 

  66. Raouf M, Bettinger JJ, Fudin J. A practical guide to urine drug monitoring. Fed Pract. 2018;35(4):38–44.

    PubMed  PubMed Central  Google Scholar 

  67. James HN. Risk management for point-of-care testing. Ejifcc. 2014;25(2):154–61.

    PubMed  PubMed Central  Google Scholar 

  68. Drummer OH. Drug testing in oral fluid. Clin Biochem Rev. 2006;27(3):147–59.

    PubMed  PubMed Central  Google Scholar 

  69. Bosker WM, Huestis MA. Oral fluid testing for drugs of abuse. Clin Chem. 2009;55(11):1910–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Dams R, Choo RE, Lambert WE, Jones H, Huestis MA. Oral fluid as an alternative matrix to monitor opiate and cocaine use in substance-abuse treatment patients. Drug Alcohol Depend. 2007;87(2–3):258–67.

    Article  CAS  PubMed  Google Scholar 

  71. Cone EJ. New developments in biological measures of drug prevalence. In: Harrison L, Hughes A, editors. Validity self-reported drug use Improv Accuracy Surv Estim. Bethesda: National Institute on Drug Abuse; 1997.

    Google Scholar 

  72. Verstraete AG. Detection times of drugs of abuse in blood, urine, and oral fluid. Ther Drug Monit. 2004;26(2):200–5.

    Article  CAS  PubMed  Google Scholar 

  73. Crouch DJ. Oral fluid collection: the neglected variable in oral fluid testing. Forensic Sci Int. 2005;150(2–3):165–73.

    Article  CAS  PubMed  Google Scholar 

  74. Lotsch J, von Hentig N, Freynhagen R. Cross sectional analysis of the influence of currently known pharmacogenetic modulators on opioid therapy in outpatient pain centers. Pharmacogenet Genomics. 2009;19:429–36.

    Article  PubMed  Google Scholar 

  75. Barakat N, Atayee R, Best B. Relationship between the concentration of hydrocodone and its converstion to hydromorphone in chronic pain patients using urinary excretion data. J Anal Toxicol. 2012;36:257–64.

    Article  CAS  PubMed  Google Scholar 

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Chakravarthy, K., Goel, A., Jeha, G.M. et al. Review of the Current State of Urine Drug Testing in Chronic Pain: Still Effective as a Clinical Tool and Curbing Abuse, or an Arcane Test?. Curr Pain Headache Rep 25, 12 (2021). https://doi.org/10.1007/s11916-020-00918-z

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