Urine Drug Screen ....surprise!

jelnurse · Dec 22, 2016

I think that sort of situation calls for direct frank discussion with the patient with two clinicians present, preferably with everyone seated so no one looks extra intimidating. Of course be sure the test is correct. If it was just a "dipstick" test, get a real one using gas chromatography, then start the conversation with virtually certain confidence the test results are correct.

Talk with her with a strong bias toward discovering a mental health problem that she is treating with the benzodiazepines. She might be using the benzodiazepines to relieve anxiety, and she might have been using the hydrocodone for the same reason. Maybe the benzodiazepines are just to fill in after she runs out of hydrocodone each month.

Have a referral ready for a mental health evaluation from either a psychiatrist or psychiatric NP, and offer to continue pain treatment while that referral is being planned, but insist on bi-weekly urinalysis and pill counts - she shows up, or she gets no Rx.

Drug abusers have a horrible problem, and I think we have a moral and clear ethical duty to help without just throwing them out. If this is her first time "caught" abusing two drugs (using benzo's and NOT using hydrocodone is TWO abuses in my opinion), then be frank but supportive. Include early in the discussion that you intend to keep treating her, and if she has a pain condition, even assure her you intend to keep using the hydrocodone with special arrangements to make sure she uses it correctly.

Unless you also are a lawyer, do not give her legal advice per se, but DO remind her that selling or sharing hydrocodone is a serious crime, and so is acquiring benzodiazepines without a Rx. Make it clear you intend to help her, and actually plan to do so. In all that you do and say to her, be genuinely biased toward helping her and not just getting rid of her.

Consider exotic scenarios, but those usually are not what's happening. Of course, be open to the possibility that she is being abused and forced to hand over the hydrocodone to someone. Benzodiazepines sure would make a person more cooperative with an abuser, so maybe the benzo's are being forced on her. That sort of thing certainly does happen. You might even want to start the next assessment with a focus on whether she is safe or being abused by anyone. If she is, that will sure affect how the interview continues.

agrayRN, MSN, APRN, NP · Dec 22, 2016

Wow. I'm assuming that since she is being tested, she is taking these routinely for chronic pain. I think before assuming anything, I would have a conversation with her (after checking INSPECT). Explain that her urine test results show that she's not taking her Norcos, and that she is taking some type of benzodiazepine. Try to get her side of the story. Obviously something fishy is going on, though, so you would have to stop prescribing the Norco. It's sad that these things happen, but it seems to happen more and more frequently. It happens a lot in my area. I work in a neuro practice now, so thankfully I don't deal with it much anymore. I can't imagine working in pain management.

casias12 · Dec 23, 2016

I think that sort of situation calls for direct frank discussion with the patient with two clinicians present, preferably with everyone seated so no one looks extra intimidating. Of course be sure the test is correct. If it was just a "dipstick" test, get a real one using gas chromatography, then start the conversation with virtually certain confidence the test results are correct.
Talk with her with a strong bias toward discovering a mental health problem that she is treating with the benzodiazepines. She might be using the benzodiazepines to relieve anxiety, and she might have been using the hydrocodone for the same reason. Maybe the benzodiazepines are just to fill in after she runs out of hydrocodone each month.
Have a referral ready for a mental health evaluation from either a psychiatrist or psychiatric NP, and offer to continue pain treatment while that referral is being planned, but insist on bi-weekly urinalysis and pill counts - she shows up, or she gets no Rx.
Drug abusers have a horrible problem, and I think we have a moral and clear ethical duty to help without just throwing them out. If this is her first time "caught" abusing two drugs (using benzo's and NOT using hydrocodone is TWO abuses in my opinion), then be frank but supportive. Include early in the discussion that you intend to keep treating her, and if she has a pain condition, even assure her you intend to keep using the hydrocodone with special arrangements to make sure she uses it correctly.
Unless you also are a lawyer, do not give her legal advice per se, but DO remind her that selling or sharing hydrocodone is a serious crime, and so is acquiring benzodiazepines without a Rx. Make it clear you intend to help her, and actually plan to do so. In all that you do and say to her, be genuinely biased toward helping her and not just getting rid of her.
Consider exotic scenarios, but those usually are not what's happening. Of course, be open to the possibility that she is being abused and forced to hand over the hydrocodone to someone. Benzodiazepines sure would make a person more cooperative with an abuser, so maybe the benzo's are being forced on her. That sort of thing certainly does happen. You might even want to start the next assessment with a focus on whether she is safe or being abused by anyone. If she is, that will sure affect how the interview continues.

Not trying to be insensitive, but this just doesn't happen in the real world. A $55 office visit just doesn't cover all of that, and it happens often enough, a clinician just has to have a plan ready.

This fabricated scenario was presented to see what clinicians would do when faced with this.

I would continue to decrease her medications and offer non-opioid alternatives, and refer to rheumatology for the osteo, referral to spine clinic for low back pain.

Depending on her co-pay, a patient like this may or may not go to these, or any other therapy.

allnurses Guide · Dec 27, 2016

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.

This patient wasn't presented as a sparing prn Vicodin user, at least I didn't gather that from the OP. She has been on Vicodin for 18 months and presents looking to essentially double the dose, it would be really unusual for a sparing prn user to present that way.

I have had a patient use that excuse before though; when the records indicate that they fill them at exactly 28 days every month it would mean that they are at very least not taking the meds as prescribed, which is part of our contract.

Of course it is possible for a patient to have been out of meds for 2+ days but this seems like quite a surprise in the OP.

allnurses Guide · Dec 28, 2016

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.

That sounds like a reasonable plan.

casias12 · Dec 28, 2016

This patient wasn't presented as a sparing prn Vicodin user, at least I didn't gather that from the OP. She has been on Vicodin for 18 months and presents looking to essentially double the dose, it would be really unusual for a sparing prn user to present that way.
I have had a patient use that excuse before though; when the records indicate that they fill them at exactly 28 days every month it would mean that they are at very least not taking the meds as prescribed, which is part of our contract.
Of course it is possible for a patient to have been out of meds for 2+ days but this seems like quite a surprise in the OP.

It wasn't a surprise to me. I just wanted to present it that way to see what comments would be generated. This was a fictitious patient, but it did present several legitimate scenarios.

1) Trading drugs for something else.

2) Over-using prescribed drug and running out way too soon.

3) False readings on UDS.

4) Hoarding old medications and using them in times of need.

5) Household that has red flags for prescribing controlled substances.

6) Use of opioids for chronic pain without adjunct therapies.

7) Use of opioids for neuropathic pain.

8) Need to educate patient about the mechanism of her pain, and help develop an appopriate plan for treatment.

Anyway. Some good comments. Have a great New Year!