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?

[Emergent, RN]

Is she trading her Norcos with a friend or relative for their xanax?

[NSC Nursing]

Hoslistic care at its finest. She may be selling the pills to provide for her grandkids due to possibility of financial stuggle. I would love to hear the outcome

[NSC Nursing]

Could the benzo result be from escitalopram

[annabanana2]

(Obligatory disclaimer: not an APRN, just a regular RN)

TONS of my elderly home health clients have young family members that will either outright steal their opioids or "trade" them for "something better." They're happy to give away and receive pills willy-nilly. They see no reason why it's dangerous or otherwise not okay to take someone else's prescription. In their minds medications are basically possessions like golf clubs or wooden spoons, so why not lend a few to little Timmy who's complaining of back pain and whose big mean doctor won't let him have any Tylenol 3? Of course, as a previous poster said, she may also be selling them and buying benzos instead, maybe she can turn a profit that way, who knows.

I mean, not saying this is what's happening with your patient necessarily. I just... my mind was blown when I first realized this was happening with my clients. And usually if I were to ask them, "hey, your UDS came up positive for benzos and negative for opioids, what's the deal with that?" they would probably be honest with me. What did your patient say?

[kbrn2002, ADN, RN]

The first and most obvious conclusion is she is not taking her prescribed pain meds. Which of course would mean that somebody else is and that opens a whole other can of worms. However, before you jump to that conclusion did anybody ask when she had her last dose? It's not impossible that she simply ran out of meds before her appointment and may be "borrowing" somebody's benzo's to help with pain until she gets more hydrocodone. That could be an explanation for why she is asking for a dose increase. After all hydrocodone has such a short half life that even with regular use it only shows up in a urine drug screen for 2-7 days. If running out of meds is the reason she is asking for a dose increase she needs better pain management, not accusations that she is selling and/or trading her meds.

[amoLucia]

How is she financing all her 'other' meds? Some of them can be rather pricey even with some insurance $ coverage.

[Jules A, MSN]

My biggest issue with this is the likely possibility of benzos with opiates and the implications that combo could present so that discussion should hopefully flesh out which of the above scenarios might be happening. Although always a good avenue to consider I'd seriously doubt the Lexapro resulted in the positive UDS. Despite whether her pain is controlled taking additional medication that are not hers is not only dangerous but it is illegal. I'd say some patient education in addition to serious monitoring going forward would be required. Benzos or opiates with OSA is a concern imo. I'm so not a fan of opiates for long term pain control mostly because I have never seen any evidence they are effective long term but also because of the whole host of problems that almost always accompany their use. Among the red flags for me would be the specific dose request and reluctance to do the urine drug screen. I would be likely to work on a taper/dc plan for her in addition to suggestions/referrals to non-pharm strategies for pain control.

[BostonFNP, APRN]

There are some concerning details here: she's chronically taking a short acting narcotic for (what I assume) is low back pain in the setting of obesity, she is a stage 1 COPD so I assume a ?smoker which is an independent risk factor for script abuse, and she is asking for a med by name/dose.

On the flip side, she does seem to have difficulty on exam.

The benzo positive is concerning but not my "problem"; sure it is something to talk about.

The narcotic negative is my problem and under our contract would be grounds for discontinuation without taper. I would need to have a conversation with the patient about her med usage and her symptoms, review her CS monitoring, ad discuss more appropriate treatment if applicable.

[Jules A, MSN]

The benzo positive is concerning but not my "problem"; sure it is something to talk about.

.

You are a seasoned provider and I have no doubt you would wrap this up appropriately however for those who aren't well versed in this arena I'd be careful about blowing this off as someone else's problem because it will quickly become your problem if she dies from respiratory depression or stops the benzos abruptly, seizes and it wasn't documented thoroughly that you had a full IRBA discussion. Trust me "the only reason" she started abusing benzos will later be reported as because she was in such agony after you cut her off the percs sans taper, mourning children and grandchildren making these claims won't help you case. Also consider the off chance that she was getting the benzo from another provider and you either didn't know or knew and didn't attempt to contact the other prescriber to decide who was going to stop prescribing one of this combination. I'm getting letters constantly from the CDC, DEA and pharmacies indicating the dangers when patients are taking benzos with opiates so I have zero interest in attempting to explain why this was happening either in court or to the board of nursing.

[BostonFNP, APRN]

You are a seasoned provider and I have no doubt you would wrap this up appropriately however for those who aren't well versed in this arena I'd be careful about blowing this off as someone else's problem because it will quickly become your problem if she dies from respiratory depression or stops the benzos abruptly, seizes and it wasn't documented thoroughly that you had a full IRBA discussion. Trust me "the only reason" she started abusing benzos will later be reported as because she was in such agony after you cut her off the percs sans taper, mourning children and grandchildren making these claims won't help you case. Also consider the off chance that she was getting the benzo from another provider and you either didn't know or knew and didn't attempt to contact the other prescriber to decide who was going to stop prescribing one of this combination. I'm getting letters constantly from the CDC, DEA and pharmacies indicating the dangers when patients are taking benzos with opiates so I have zero interest in attempting to explain why this was happening either in court or to the board of nursing.

I should have explained more. The benzo is a problem; when I say it's not "my problem" was that regardless of the positive bezno, the same issue remained with the narcotics. There is no explaining away the negative. The positive could be any number of things: false positive from other meds in her regimen, an ED visit, another prescriber, an old script, or it could be abuse or a substituted med by family trying to manage stealing scripts (though the patient is awful young for that).

[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.