Urine Drug Screen ....surprise!

[casias12]

I thought I would present a case that occurred recently at our practice. For the purpose of anonimity, we can assume that all of the identifying details have been changed.

A very pleasant 68-year-old female with past history of obesity, HTN, HLD, sleep apnea (not using CPAP due to "claustrophobia")Stage 1 COPD, osteoarthritis, chronic low back pain, Type II DM, anxiety and depression is being seen for regular follow-up appointment. She has been receiving hydrocodone/apap 5/325 for 18 months.

Medications are lisinopril, hctz, simvastatin, metformin, advair, albuterol, famotidine, escitalopram and hyd/apap 5/325.

She lives with her grown son and daughter-in-law, and 2 young grandchildren.

She presents today reporting stiffness and tenderness of her fingers and low back. She has not suffered any recent trauma, and has not had any change in her overall condition. She denies fever, chills, weight change, loss of appetite, SOB, CP, dyspepsia, change in bowel or bladder, and reports her FBS has been

On exam, you find a pleasant, portly lady who has some difficulty getting to the exam table, and has mild tenderness of hands and low back on palpation. Otherwise, her physcial exam is as expected, and VS are WNL.

She asked for the hydrocone/apap to be increased to "10 mg" (her words).

So, how about that urine drug screeen? How many NP's are doing random UDS in their practice before prescribing opioids?

Initially, she tries to avoid the UDS. "I've never had to do this before. I'm not using any drugs. Why do I have to do this? I just used the bathroom, I can't go right now".

Reluctantly, she agrees.

Her UDS comes back positive for benzodiazepines, negative for opioids.

WTH?

Thoughts?

[SeasonedOne, RN]

The scenario speaks to mild tenderness and a relatively compliant patient on narcotic pain pills for the last 18 months.

My questions are as follows:

1. Why was she given the pain meds in the first place. Mild pain can be managed with NSAIDS or similar. Is this what she is using and only takes the Rx when pain is severe?

2. What is the source of her depression and anxiety and why isn't the MD/NP/PA office visits addressing this?

3. If the weight is why she is living with family and has an impact on mobility, why isn't this being addressed as well.

4. She is pleasant to staff but what is her relationship to the other family members. Is she hesitant to do the drug screen because it will lead to more questions on possible intimidation/psychological abuse or family taking her pills. She may not be forthcoming as the Rx is what keeps the family off her back. Where else will she go...what are her choices if she is low income.

5. Other points made could also have a barring on this situation.

Nothing is ever clear unless you do additional digging....and then the waters can get really muddy.

[casias12]

All good answers and queries.

We use a contract, and check the PDMP database every time we see a patient for a controlled substance refill. There were no benzo prescriptions on the list for her. A couple of comments that stand out, in no particular order.

1. "the benzo is not my problem", post 8. In our contract, having another controlled substance by any other prescriber is cause for a warning to the patient. Having an old script and using it after signing the contract is also a warning. Having no prescription, but positive urine screen results in a 7-day refill and follow up office visit. With benzo, which can stay in the system for a long time, I wouldn't do a repeat UDS at that visit, but it might leave the patient concerned about it.

2. "Does anyone count pills". post 11. I always look at the PDMP and say, "Ok, so you had 90 hydrocone filled on x, date, how many of those do you have now?". We don't do a physical count. But the most common answer we get it, "I just ran out yesterday". We write the new prescription for the correct date, even if they ran out early.

3. False positives. We send the UDS out for lab confirmation if it is suspect.

4. Negative result on UDS. Less of a problem, at least early on. Like someone pointed out, opiates can clear the urine in as little as 2 days, so if she ran out, she could explain that away.

5. Non-opioid alternatives. Clearly, her osteoarthritis and low back pain should be managed with other agents, and are likely different types of pain. Both are probably a combination of nociceptive pain and neuropathic pain, caused by inflammation. So other medications should be considered.

SO...what did I do. I warned her about the implications of not using her meds correctly. I refilled her hyd/apap at the 5/325 dose for 7 days. Gave her a medrol dose pack, and Lyrica, and arranged for a 7-day follow up. I will likely change her to tramadol at the next visit, since it is probably a better choice for her anyway.

[BostonFNP, APRN]

Interesting, you refilled her narcotic even though she tested negative?

[chiromed0]

Ha...I'm in pain management. Everyone gets UDS with confirmation. Prescription records checked every visit. Psych evals every visit. Even with all these safeguards we are still pretty strict on what we prescribe. You can never control what happens after they pick up their meds but at least you can try to do your due diligence before you write for them.

[Jules A, MSN]

Ha...I'm in pain management. Everyone gets UDS with confirmation. Prescription records checked every visit. Psych evals every visit. Even with all these safeguards we are still pretty strict on what we prescribe. You can never control what happens after they pick up their meds but at least you can try to do your due diligence before you write for them.

Sounds like a well run practice, kudos.

[RunNP]

I feel for those of you who deal with the chronic pain issue and drug seekers. I remember in school how they carried on about the contracts, pill counts and urine tests for people on pain med contracts. In my clinical rotations it seemed to be a daily issue or daily headache.

[BostonFNP, APRN]

In my clinical rotations it seemed to be a daily issue or daily headache.

One of our local doctors got fed up with it last year and she just decided to stop writing narctoics. She felt like it took too much time away from other patients. She can't stop talking about how much it made her work life better. She uses Toradol for acute pain/episodic visits and she refers to the local pain specialist for chronic issues.

[MunoRN, RN]

Interesting, you refilled her narcotic even though she tested negative?

If the patient was using a short acting prn opiate appropriately it wouldn't be unusual for them to test negative on a UDS. I'm not sure why you would take away their medication because they were using it appropriately, although I would argue in general that opiates are not appropriate for long term use except for in rare situations.

[Jules A, MSN]

If the patient was using a short acting prn opiate appropriately it wouldn't be unusual for them to test negative on a UDS. I'm not sure why you would take away their medication because they were using it appropriately, although I would argue in general that opiates are not appropriate for long term use except for in rare situations.

Speaking only for myself if a patient is tox positive for benzos when I'm prescribing opiates or vice versa that is reason enough for me to discontinue, with taper if indicated, whatever I'm writing. I'm not playing around with that and am upfront about that from the beginning.

[casias12]

Interesting, you refilled her narcotic even though she tested negative?

I did.

As others have said, we sent out the urine for confirmation and I gave her the one week refill and a follow up. I don't jump to any conclusions on a dipstick test, unless it shows an illegal substance.

When patient came back in a week, she admitted that she had some old alprazolam, and had run short on the hydrocodone, but she also had some relief from the medrol dose pack, and Lyrica.

Hydrocone was decreased to BID. She was counseled on using her medications appropriately, and not hoarding them. We'll see how she does.

[Jules A, MSN]

I did.

As others have said, we sent out the urine for confirmation and I gave her the one week refill and a follow up. I don't jump to any conclusions on a dipstick test, unless it shows an illegal substance.

When patient came back in a week, she admitted that she had some old alprazolam, and had run short on the hydrocodone, but she also had some relief from the medrol dose pack, and Lyrica.

Hydrocone was decreased to BID. She was counseled on using her medications appropriately, and not hoarding them. We'll see how she does.

Sounds reasonable, I'm guessing you calculated and she didn't run out because she was taking too many. Hopefully she's amenable to non-pharm interventions. Good thread!

[amoLucia]

Interesting topic esp from those of you in office practices and/or prescriptive auth.

When I was looking for a new PMP provider because my insurance had changed, I selected one ,and told them I was to be a 'new pt'. Were they accepting new pts?

Their next sentences were "yes, we take new pts" but "no, we don't Rx opiods or benzos". Like the receptionist said it all in one breath!

OK for me because I don't use the heavy duty meds - they make me 'stupid'. Don't like them.