Marc R Larochelle1, Ricardo Cruz2, Sarah Kosakowski2, Doug L Gourlay3, Daniel P Alford2, Ziming Xuan4, Erin E Krebs5, Shapei Yan2, Karen E Lasser2,4, Jeffrey H Samet2,4, Jane M Liebschutz6. 1. Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, USA. marc.larochelle@bmc.org. 2. Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, USA. 3. Private Practice, Hamilton, ON, Canada. 4. Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA. 5. Minneapolis VA Health Care System, University of Minnesota Medical School, Minneapolis, MN, USA. 6. Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Abstract
BACKGROUND: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN: Retrospective cohort study. SUBJECTS: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.
BACKGROUND: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN: Retrospective cohort study. SUBJECTS: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.
Authors: Jane M Liebschutz; Ziming Xuan; Christopher W Shanahan; Marc LaRochelle; Julia Keosaian; Donna Beers; George Guara; Kristen O'Connor; Daniel P Alford; Victoria Parker; Roger D Weiss; Jeffrey H Samet; Julie Crosson; Phoebe A Cushman; Karen E Lasser Journal: JAMA Intern Med Date: 2017-09-01 Impact factor: 21.873
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Authors: Charles E Argoff; Daniel P Alford; Jeffrey Fudin; Jeremy A Adler; Matthew J Bair; Richard C Dart; Roy Gandolfi; Bill H McCarberg; Steven P Stanos; Jeffrey A Gudin; Rosemary C Polomano; Lynn R Webster Journal: Pain Med Date: 2018-01-01 Impact factor: 3.750