Once more we will delve into the minutiae of an issue…this time into testing patients who are prescribed opioids to ascertain if they are taking the prescribed medications, and if there is evidence they are consuming other licit and/or illicit drugs.
(full disclosure – Millennium Health, the largest toxicology testing company, is a consulting client)
All guidelines suggest/encourage/require testing of patients prescribed opioids.
There are two types of urine drug tests – qualitative, where a cup test simply indicates if a drug is or is not present, and quantitative, which is much more accurate and must be done in a lab.
I’m surprised at the continued use of qualitative tests as they are notoriously unreliable; research indicates the cup test failed to show benzodiazepines were present for 28% of specimens, and cocaine for fully half of specimens evaluated – and false negatives and positives for other drugs are much higher than one would expect. These “false negatives” are obviously misleading; the usefulness of cup tests is further compromised by how easy they are to fool. (there are about a gazillion web pages that provide info on passing a cup test…)
Except, if your sample gets sent to a lab for quantitative testing. It is much harder to fool good lab testing because the testing equipment:
- uses much lower cutoff levels for drugs, thereby finding more positives than cups do;
- tests for metabolites – the chemicals created by your body after it processes the drugs: metabolites show you’ve actually taken the drug
- checks for certain chemical markers that can indicate if the urine is fake or from another person (or, in some cases, another animal)
There’s much more to this; warning, if you start looking around on the web, you’ll find some incredible stories and myths and tales about folks allegedly passing tests; great for entertainment but very easy to become mesmerized for hours.
I recently reviewed data from a very large sample, specifically looking for data about cup results vs lab (quantitative) results. The analysis was rather disturbing…Cup tests missed:
- 45% of opiates (cup reported no opiates, lab reported opiates)
- 44% of benzodiazepines
- 28% of marijuana
Cup tests also indicate drugs are present when the lab tests show they are not, false positives occurred in:
- 27% of reported opiates
- 69% of antidepressants
- 100% of PCP
What does this mean for you?
Be very careful about basing decisions on cup tests – even if they show there aren’t any anomalies or “unexpected” results.
Interesting, what about all those people who want tests of Disability claimants, or welfare or unemployment claimants? I have heard the courts wouldn’t allow it, but I still get E-mails from friends, acquaintances, who feel it should be done
Interesting post. My impression has been that the in-office cup tests were more about revenue generation and less about adherence management. That being said, once you do have some valid results they need to be acted upon. I find it interesting that in New York, the WC Board legal counsel opines that it is illegal for an insurance carrier or PBM to talk to a doctor about the results of a drug test or to share ideas on how to manage pharmacy care in the event of an aberrant test. Basically leaving the prescriber to “self-police” their own prescribing practices and patient adherence, and possibly left to guess how to best approach a non-compliant test. I am all for quantitative drug testing, but like any tool, any unexpected results require action and a collaborative approach to addressing any issues revealed by the testing. It really doesn’t make sense to test, for testing’s sake, and then not create an environment where the best action can be taken to help the injured worker through a difficult situation.
Joe, can you delve into the pricing of these tests? I’ve seen many test results which indicate the injured worker isn’t taking the prescribed medication, yet the prescribing physician fails to do anything or even ask the injured worker about the results. Those results are attached to a bill for several thousand dollars for the test, which was neither requested, authorized or even of any value since the physician has done nothing with the results.
Thank you for the article and stats, this is a hot topic with the payors who don’t want to pay for the comprehensive testing.
Thank you for this brief overview. It is important to educate people about kinds of lab testing, however, the fact that this was informed by Millennium Health laboratories explains why you have not included a key and very important version of urine drug screening that is widely available. Immunoassay testing can be done by card/dip tests, and yes, it is renowned for having both false positive results and for false negative results. In addition, the person reading the card/cup can misinterpret the results easily. What you didn’t mention is that another version of a screening test (also done via Immuno-Assay) which is much cheaper…. can be done in a laboratory on an Immuno-Assay laboratory chemistry analyzer machine for hundreds of dollars less than the definitive quantitative testing you describe. This screening testing is not definitive, but has a very high degree of accuracy, can test for many kinds of substances 20+. Quantitative definitive testing is rarely needed clinically. Quantitative implies you know the “exact” amount of substance in the specimen. That is rarely necessary. The clinicians need to know that a substance is present, or it is not, with accuracy. There is little value to knowing the exact amount of substance in the specimen, which is what high complexity quantitative testing does, and which is quite costly. Recently national labs have come under great scrutiny for encouraging physicians and other health care providers to use more complex testing than is medically necessary. So, I would encourage you to get additional advice regarding available screening tools when making recommendations to Insurers, providers and workers compensation organizations who all share the vision of providing high quality care in a cost conscious way.
Dr Wilson – thanks for the comment. Allow me to address your points individually.
First, you state ” the fact that this was informed by Millennium Health laboratories explains why you have not included a key and very important version of urine drug screening”..
I’m puzzled as to why you would make that statement. It appears you are drawing a conclusion by inference which is not supported by anything other than that inference and, as frequent readers of this blog, completely unsupported by past history. I noted MH is a client because I always do when a client is relevant to a topic – not because they “informed” the post.
Second, your statement re the “Immuno-Assay laboratory chemistry analyzer machine for hundreds of dollars less than the definitive quantitative testing you describe.” is based on a false premise, namely you assume the cost is “several hundred dollars” less for the IA than the lab quantitative test. I have seen bills for IA testing that were significantly higher than LC/MS-MS tests done by actual labs. I have many payer clients who are paying less than $500 for a comprehensive, full-panel quantitative test. Of course, workers’ compensation reimbursement is driven in large part by fee schedules which do vary greatly by state.
Third, re your statement that IA “screening testing is not definitive, but has a very high degree of accuracy, can test for many kinds of substances 20+. Quantitative definitive testing is rarely needed clinically…clinicians need to know that a substance is present, or it is not, with accuracy. ” is puzzling, as CMS does NOT appear to concur with your statement re accuracy. I refer you to CMS’ recent review of IA testing and this excerpt:
Presumptive UDT testing [referring to IA testing] is limited due to:
Primarily screens for drug classes rather than specific drugs, and therefore, the practitioner may not be able to determine if a different drug within the same class is causing the positive result;
Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs within a drug class;
Not all prescription medications or synthetic/analog drugs are detectable; it is unclear as to whether other drugs are present
Cut-off may be too high to detect presence of a drug
This information could cause a practitioner to make a wrong assumption.
I would also note that data indicates about 18% of workers’ compensation patients tested have no indication in their results that they are taking the drugs prescribed. As workers’ compensation payers must make coverage and other determinations based on the best possible evidence (WC is a legal system), the most accurate and precise measurement methodology (including collection) is mandatory.
I did not assert that knowing the precise level of substance is necessary, rather that quantitative testing is more precise and more accurate, uses different cutoff points, and therefore more suitable in this system.
Thanks for reading MCM.
This topic is not unlike prosecuting gun crimes while dodging the issue of gun proliferation, which apparently is off-limits in our country despite ample global evidence from other developed countries that gun control works.
With that provocative digression, back to opiates. We know that our morphine equivalent per capita is massively more than other countries and has soared in recent decades, thanks to the billionaire Sackler family (Ocycontin) and others.
I was taught in my training that opiates have a place in acute and terminal pain, not in chronic pain. Nothing I have seen suggests otherwise since, and in fact, the intervening decade long experiment of using opiates for chronic pain has been and continues to be a tragic failure.
So why are we testing for drug compliance when the best clinical path is non-prescribing. Then one might test for drug abuse if they wish.
They key is likely doctors who won’t say no, either because they are profit driven and fear empty waiting rooms, because they have truly bought the hype, or they are frightfully naive and can’t see a con if it is jumping up and down in front of them.
If the profession just shut down their prescription pads after the acute phase of injury, the legal supply would dry up, diversion would stop, and lives and livelihoods would be saved. And drug testing would no longer be needed.
Until the day you experience chronic pain and what comes along with it.. with respect sir.. I have experienced chronic pain for along time had surgeries been on life support and now watch my children grow up struggling to keep up with them my pain is kept in check by pain medication it not only helps my quality of life but my children as well. I pray for you not all are cons
Very informative article, Joe. Getting these tests into the “hands” of labs rather than those of physician’s seems to be a key component. This helps to premeditate 1) the right type of test (oral, urine, pharmocogenetic) and 2) the correct plan of action. I’ve seen these physician office urine cup tests, with no quanitative measurement, carry charges of $600-$900. If the test comes back with need for escalation, there is typically no escalation that happens. There are no data reports sent back to payer for measurement and trending. What about coding? Are these tests even coded appropriately, or are they falling right into the physician office visit category? It’s important to find a program that checks for alcohol as well (with quantitative measurement being key here). Lives can be saved when issues are identified with individuals who may be taking opiates and consuming alcohol. Also, without a quality program in place, there is no watchful eye kept on frequency (high risk patients v. low risk patients). These programs are essential in our industry to help identify abuse, fraud, diversion of scripts, etc…
To Dr Grant, obviously you have never had degenerative disc disease and 2 failed back surgeries with neuropathy as a cherry on top. Since you think opiates do not work for chronic pain I hope I never meet you or we will have words. I cannot get out of bed at all without my medications. I have never taken too many not sold them but always use as I am supposed to use them. If and only if you start having chronic pain may you only receive tylenol. You were apparently at the bottom of your medical school class. I graduated at the top of my nursing class and my ARNP class. I was a nurse for 40 years. I would be happy to get you have been practicing for less than 4 years. Don’t deprive people with chronic pain opiate medication because of addicts. There has always been addicts and always will be.
Amen !! Drives me crazy some days. If the only knew how hard walking across the room is some days!