A literature search was conducted using the following key words: drug testing; drug testing guidelines; controlled substances; urine drug testing; immunoassay; screening drug tests; definitive drug tests. The literature search was filtered to locate articles within 5-10 years, full-text articles, clinical trials, and systematic reviews.
This evidence review focuses on UDT testing used to guide treatment and whether the evidence behind this testing is adequate to draw conclusions about improved health outcomes for the Medicare population. In general, health outcomes of interest include patient mortality, morbidity, quality of life, and function.
Urine Drug Testing – Presumptive Testing and Definitive Testing in Pain Management Patients
Drug use can be detected through various biological samples such as urine, blood, oral fluid, exhaled breath, sweat, and hair. Different matrices have advantages and disadvantages concerning sensitivity and specificity with various time windows, time to obtain results, unique susceptibility to sample tampering, and ease of collection. Generally, urine is the most common agent for drug testing as it has a longer window of detection compared to blood, has a sufficient specimen quantity for drug screening and confirmation, and drug markers (parent drug or metabolites) are revealed in high concentrations.2
Currently, urine drug testing (UDT) is considered the standard for adherence monitoring of patients taking controlled substances for management of chronic pain. Evidence-based guidelines recommend UDT for the detection of applicable over-the-counter (OTC) medications, prescribed and nonprescribed drugs, and illicit substances in pain management patients (quality of evidence II) (strength of recommendation B).2
There are two primary types of UDTs, presumptive and confirmatory tests. Presumptive UDT, also referred to as a screening immunoassay, may be used in the laboratory or in the office/clinic setting with point of care testing (POCT), producing relatively rapid results.5 Three primary immunoassays are used: 1) Enzyme-multiplied immunoassay technique, 2) Enzyme-linked immunosorbent assay (ELISA), and 3) Fluorescence polarization immunoassay. Generally, immunoassays utilize antibodies to detect the presence of drug metabolites or classes of drug metabolites in the urine.5 Presumptive test results are a) read by direct optical observation only, b) read by instrument-assisted direct optical observation, or c) performed by instrument chemistry analyzers.6
Immunoassays usually have variable sensitivity and specificity; therefore, substances may be missed leading to inaccurate results. For example, immunoassays will detect substances with similar characteristics, resulting in cross-reactivity leading to false-positive results.5 UDTs are usually enzyme immunoassays that target amphetamines/methamphetamines, cannabis, cocaine, phencyclidine, and opioids and are based on a specific antidrug antibody reaction. Opiate immunoassays can detect naturally occurring opiate alkaloids more accurately (i.e., morphine, codeine) than frequently prescribed synthetic (e.g., fentanyl, methadone) and semisynthetic (e.g., buprenorphine, oxycodone, oxymorphone, hydromorphone) opioids. Immunoassays are somewhat semiquantitative (i.e., an estimate of levels only) because of cross-reaction across multiple drugs. Sensitive options are currently available for testing many common drug classes.
Negative results are generally used to exclude drug abuse. Positive samples are typically sent for definitive laboratory-based testing to identify the drug(s) present and to establish adherence or identify abuse or diversion.2
The provider will need to use clinical judgment, patient history, and collaborative information to determine if definitive/confirmatory testing is necessary for optimal care of the patient.5 Evidence-based guidelines recommend definitive testing for any immunoassay (laboratory-based or POCT) result that is inconsistent with the clinical expectation in a pain management patient (quality of evidence III) (strength of recommendation A).2
Definitive UDT can be utilized for initial or confirmatory testing and involves qualitative or quantitative gas chromatography (GC)–mass spectrometry (MS), liquid chromatography (LC)–MS, and LC–tandem MS (LC-MS/MS) technologies.6 Definitive testing is not as sensitive to adulterants (i.e., any substance that reduces validity of testing) and decreases the probability of inaccurate or false results. Definitive testing can accurately identify metabolites, verifying that a parent drug was truly ingested; definitive testing can also detect potentially abnormal opioid metabolism.6
Evidence-based guidelines recommend specimen validity testing (e.g., pH, temperature, creatinine, oxidants) as it is a valuable means to ensure outcomes (e.g., use of relevant OTC, prescribed, and non-prescribed drugs) are accurately interpreted in pain management patients. Specimen validity testing establishes the appropriateness of the urine specimen collected/received, which impacts the capability to properly identify applicable OTC medications, prescribed and non-prescribed drugs, and illicit substances used by pain management patients (quality of evidence I) (strength of recommendation A).2
Urine Drug Testing – Presumptive Testing and Definitive Testing for Patients in Addiction Treatment and Recovery
Jarvis et al4 provides a consensus statement from the American Society of Addiction Medicine (ASAM) that offers guidance about the effective use of drug testing for patients in addiction treatment and recovery, where drug testing is utilized to evaluate patients for a substance use disorder, monitor the efficacy of a treatment plan, and support recovery. In this regard, drug testing is recommended for the following (this is not an all-inclusive list): 1) As a therapeutic tool in conjunction with evidence-based addiction treatment, 2) To explore denial, motivation, and actual substance use behaviors, 3) At intake to assist in a patient’s initial assessment and treatment planning, 4) To assist in determining optimal placement in a level of care, 5) As an objective means of validating a patient’s substance use history, 6) To support the difference between intoxication and the presence of an underlying psychiatric and/or medical condition in a patient presenting with altered mental status, and 7) To monitor recent substance utilization in all addiction treatment settings.
Opioid Treatment Services
Stratification of risk for patients started or maintained on chronic opioid therapy is vital to avoid misuse and abuse. Prior to initiating chronic opioid therapy, the provider should perform a history and physical examination and appropriate testing, involving an evaluation of risk of substance abuse, misuse, or addiction.7
The principal objectives of drug testing in opioid treatment services (OTS) are: a) Identifying substance use that could complicate treatment response and patient management, b) Monitoring for adherence with the prescribed medication, and c) Monitoring for potential diversion.4 Clinical drug testing for OTS is utilized for the goals of diagnosis, monitoring, and evaluating progress in treatment and in the promotion of long-term recovery. Drug testing detects the patient’s use of specific drugs and establishes the absence of prescribed medications that may be an indication of diversion. The frequency of drug testing is determined by assessing the clinical appropriateness in relation to the patient’s stage of treatment and risk stratification.7-8
Providers should utilize UDT before a patient starts taking opioids for chronic pain and periodically during opioid therapy based on risk factor analysis to evaluate for prescribed opioids in addition to other controlled substances and illicit drugs that raise the risk for overdose when mixed with opioids, including nonprescribed opioids, benzodiazepines, and heroin.7,9
Presumptive UDT is recommended at initiation of opioid therapy and subsequently as adherence monitoring, using in-office POCT. Qualitative immunoassay drug testing prior to prescribing controlled substances may be utilized to detect some illicit drug use and reduce adverse outcomes in pain management patients (quality of evidence II) (strength of recommendation B).2
Definitive testing may be needed in select patients to identify specific opioids that cannot be detected on standard immunoassays or for unexpected UDT results. However, providers should not test for substances in which results would not affect patient management.7,9 Random drug testing is required a minimum of eight times per year for patients in maintenance opioid treatment programs.8,10
American Association for Clinical Chemistry (AACC) Academy Laboratory Medicine Practice Guideline Recommendations for UDTs
Jannetto et al2 provides the AACC Academy laboratory medicine practice guidelines that offer evidence-based recommendations for the utilization of laboratory and POC urine drug tests for relevant OTC drugs, prescribed and non-prescribed medication, and illicit substances in pain management patients. This document also includes expert opinion guidelines on laboratory testing for pain management which were jointly developed with the Clinical and Laboratory Standards Institute.
Per consensus-based expert opinion, random drug testing should be conducted at least one to two times per year for low-risk patients (based on history of past substance abuse/addiction, aberrant behaviors, and opioid risk screening assessment), and more frequently for higher-risk patients who are prescribed controlled substances.2 Evidence-based guidelines recommend more frequent laboratory testing for patients with a personal or family history of substance abuse, mental illness, indication of aberrant behavior, or other high-risk attributes (quality of evidence II) (strength of recommendation A).2
Overall, the evidence is weak for precise schedules for drug testing primarily due to the lack of randomized clinical trials to contrast the efficacy of testing schedules or methods particularly for patients with chronic pain. Current clinical practice guidelines recommend drug testing at baseline and randomly at least once a year for low-risk patients based on observational studies or expert consensus opinion. However, more frequent monitoring is recommended for patients with risk factors for misuse/abuse, although the ideal frequency has not been established.2
Jannetto et al2 recommends the following drug classes for testing for pain management patients based on risk:
- Amphetamines (e.g., Methamphetamine [MDMA])
- Barbiturates (e.g., phenobarbital)
- Benzodiazepines (e.g., alprazolam, diazepam)
- Cannabinoids (e.g., delta 9 - tetrahydrocannabinol [THC], 11-nor-9-carboxy-THC [THCCOOH])
- Cocaine (e.g., benzoylecgonine)
- Opiates/Opioids (e.g., hydrocodone, oxycodone)
- Anticonvulsants (e.g., carbamazepine, lamotrigine, gabapentin, phenytoin, pregabalin, valproic acid)
- Antidepressants (e.g., paroxetine, fluoxetine, citalopram, amitriptyline)
- Synthetic cathinones (e.g., methylone)
- Antitussive (e.g., dextromethrophan)
- Dissociative anesthetic (e.g., ketamine)
- Hallucinogens (e.g., lysergic acid diethylamide [LSD])
- Muscle relaxants (e.g., carisoprodol, meprobamate, methocarbamol)
- Narcotic pain-reliever (e.g., propoxyphene)
- OTC analgesic (e.g., acetaminophen, salicylate)
- Antihistamine (e.g., certirizine)
- Antipsychotics (e.g., clozapine, haloperidol, olanzapine)
- Synthetic cannabinoids (e.g., JWH-018)
Drugs of Abuse: A Drug Enforcement Administration Resource Guide
The Drug Enforcement Administration (DEA) and the U.S. Department of Justice3 provide ‘Drugs of Abuse - A DEA Resource Guide’ concerning the most commonly abused and misused drugs in the U.S. with significant information regarding the harms and consequences of drug utilization, overdose potential, origin, legal status, and other strategic information such as a description of the Controlled Substances Act (CSA).
The CSA regulates the following classes of drugs:
- Narcotics (e.g., opium, opium derivatives, and their semi-synthetic substitutes). Examples: OxyContin®, Vicodin®, heroin, codeine, morphine, methadone, and fentanyl.
- Depressants - Examples: barbiturates (butalbital [Fiorina®], phenobarbital, Pentothal®, Seconal®, and Nembutal®), benzodiazepines (Valium®, Xanax®, Halcion®, Ativan®, Klonopin®, Restoril®, and Rohypnol®), Lunesta®, Ambien®, Sonata®, meprobamate, methaqualone (Quaalude®), and Gamma-Hydroxybutyric acid (GHB).
- Stimulants - Examples: amphetamines (Adderall® and Dexedrine®), methylphenidate (Concerta® and Ritalin®), diet aids (e.g., Didrex®, Bontril®, Preludin®, Fastin®, Adepex-P®, Lomamin®, and Meridia®), methamphetamine, cocaine, methcathinone, and other synthetic cathinones that are commonly disguised as “bath salts”.
- Hallucinogens - Examples: MDMA (ecstasy), LSD, Ketamine, and hallucinogenic mushrooms.
- Anabolic steroids – Examples: testosterone, trenbolone, oxymetholone, methandrostenolone, nandrolone, stanozolol, boldenone, and oxandrolone.
- Marijuana/Cannabis (e.g., THC [delta 9 - tetrahydrocannabinol]).
- Designer drugs (e.g., synthetic stimulants). Examples: “Bath salts”, K2 and Spice (synthetic cannabinoids), and synthetic opioids.
Each class has distinguishing properties, and drugs within each class frequently produce similar effects. However, all controlled substances, regardless of class, share some common characteristics. All controlled substances have abuse potential or are immediate precursors to substances with abuse potential. When controlled substances are utilized in a method or amount not consistent with the legitimate medical use, it is referred to as drug abuse. In addition to having abuse potential, most controlled substances can produce dependence; physical or psychological.