Response to Urine Drug Testing in a Family Residency Practice

To the Editor

We read the letter submitted by Woodall and colleagues commenting on our paper, “Utility of Point of Care Urine Drug Tests in the Treatment of Primary Care Patients with Drug Use Disorders” with great interest (McDonell et al., 2016). In our paper we conclude that urine drug tests (UDTs) can be used to improve the assessment of drug use in primary care patients receiving care for substance use disorders. We observed that 40% of a primary care sample had at least one positive UDT, despite denying use on a corresponding self-report and found that 27% of respondents denied opioid drug use, despite a corresponding opioid-positive UDT.

Woodall and colleagues (Woodall et al., 2016) present data documenting the utility of UDTs in primary care for a related but separate purpose, to screen for and monitor prescribed opioid, benzodiazepines, and amphetamines in chronic pain patients treated in a family medicine clinic.

They observed high rates of medication non-adherence, as assessed by UDTs. Specifically, 40% of those prescribed opioids or benzodiazepines had UDTs that indicated no recent use of these medications. Additionally 20% of UDTs were positive for drugs not prescribed by providers. They attribute the majority of these discordant results to inaccurate patient report.

Woodall and colleagues also observed metrics of improved care as a result of implementing UDTs. Providers became more comfortable discussing UDT results with their patients, and prescribing controlled substances when random UDTs were being used. Additionally, the authors describe how they became more familiar with the strengths and weaknesses of UDTs, leading to more appropriate use of UDTs.

Our nation is faced with an epidemic of opioid misuse and many Americans suffer from chronic pain. When used in combination with self-report, UDTs are an important tool for assessing medication adherence and non-prescribed drug use when treating chronic pain patients. Yet, a recent study found only 8% of those receiving long-term opioid therapy receive a UDT (Benzon et al., 2013). Efforts such those of Woodall and colleagues are needed to increase the use of UDTs, particularly in those prescribed opioids. However, providers must be aware of the strengths and limitations of UDTs so that they can be used appropriately. To this end, ASAM has published a White Paper on drug testing (http://www.asam.org/docs/default-source/public-policy-statements/drug-testing-a-white-paper-by-asam.pdf) with the goal of educating providers about the appropriate use of UDTs (ASAM, 2013).