Urine Drug Test (UDT) Decision Support

How Often Should I Check My Patients Urine Test?

Why, When, and How they work.

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Why order a UDT:

  • Provides objective information (evidence suggests that patients may not be forthcoming if they are misusing opioids) to support the safety of the patient and of the public.

  • Demonstrates adherence to medication regimen. (Is the patient using the substance that we have prescribed to them?)

  • Demonstrates illicit substance use by patient. (Is the patient using any substances that he or she shouldn’t be?)

  • Supports recovery efforts / helps prevent misuse or abuse if patients understand urine drug tests are an ongoing part of treatment.

  • Urine drug testing is becoming the standard of care.

 How to Discuss Urine Drug Testing with Patients:

  • Some physicians feel awkward discussing urine drug testing.

  • Understanding the framework for UDT makes discussing much easier

  • TIP: Frame UDT as a personal and public health issue. Explain that it is done not to catch mistakes but to help prevent them.

  • TIP: Normalize Universal Testing – Explain that Providers cannot tell which patients might have problems with misuse. Clearly state that all patients treated with opioid medications receive this form of monitoring.

When to Perform Urine Drug Testing:

  • Most providers feel that random urine screening provides them with the best possible information.

  • Some providers use urine drug screens only when concerns arise (e.g. the patient reports that he or she is out of the opioid medication early).

  • It is also possible to perform urine drug tests on a regular, scheduled basis.

About Urine Drug Tests:

  • Initial tests are generally done with immunoassays.

  • RISKS:
    • False negatives due to cut-offs for test sensitivity
    • False positive due to cross re-activity with other drugs.
    • Unexpected findings; Send for further analysis using gas chromatography/mass spectroscopy  (highly sensitive and specific) to identify specific compounds.
    • Be aware of opioid metabolic pathways to fully analyze test results (see figure).
    • Opioid Metabolism Pathway: urine drug testing is just one piece of information that we need to integrate with everything else that we know about a patient.
    • Why patient’s UDT comes back the way that it does can never be absolutely discerned (i.e. If the urine test is negative for opioids, we don’t know if the patient is diverting medication or if he is just using it more rapidly than he should).
    • Dedicated deceivers can beat the system.


See also:

-Christo PJ et al. Urine drug testing in chronic pain. Pain Physician 2011;14:123-143.
-Heit HA and Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage 2004;27:260-267.
-Peppin JF et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Medicine 2012;13:886-896.
-Reisfield GM et al. ‘False-positive’ and ‘false-negative’ test results in clinical urine drug testing. Bioanalysis 2009;1(5):937-952.
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