Avoiding problems and miscommunications with UDS: Three scenarios

Possible overuse of UDS

Scenario: A patient contacts the Board, stating that the medical practice providing pain management care requires routine monthly UDS of all opioid patients. The patient indicates that medical insurance has deemed monthly UDS medically unnecessary and declines to cover it. The practice has advised that future UDS must be paid for out-of-pocket. The patient is reluctant, stating that all UDS tests have come back within accepted ranges.

Discussion: The Board does not have a policy that provides specific guidance on the administration of UDS. Providers are  expected to use their professional judgment to determine the appropriate frequency of UDS, if they choose to use it. NCMB encourages licensees to educate themselves about current accepted practices. UDS and other monitoring methods are covered in detail in many opioid CME courses. Check ncmedboard.org/safeopioids for a selection of free or very low cost CME opportunities.

Possible misinterpretation of UDS results

Scenario: A patient is prescribed and uses Fioricet with Codeine to manage migraines. At the request of the prescribing  physician, the patient completes a UDS. The results come back positive for morphine. The patient states that, upon receipt of the UDS results, the practice sent a dismissal letter, citing alleged morphine use. The patient is adamant the only medication used prior to the UDS was Fioricet with Codeine. The patient finds information that indicates morphine is a normal codeine metabolite. The patient wants the practice to reconsider its decision to dismiss.

Discussion: This example highlights the importance of thoroughly educating oneself about appropriate use and interpretation of UDS results, and related pharmacology. False-positive or misinterpreted UDS results may occur with office-based UDS and many commonly prescribed medications. In the instance described above, the patient was advised to write a letter to the prescribing physician explaining the circumstances that resulted in the positive UDS results.

No or poor communication to patients regarding UDS

Scenario: A patient contacts the Board after learning that UDS will be required before monthly refills of opioid prescriptions will be issued. The caller states patients were previously directed to request refills approximately three days before needed. The patient is disabled and opioid dependent and relies on a spouse for transportation to medical appointments. The patient
is concerned it will not be possible to complete UDS before a refill is needed and indicates interest in filing a complaint.

Discussion: The Board does not have an established policy on how and when patients should be notified of changes in practice policy. This example is offered as an instance of how a communication issue can spiral into serious patient dissatisfaction. In this instance, the patient was advised that filing a complaint could result in the patient’s dismissal. The patient was advised to contact the practice to request a partial refill to allow additional time for the patient to comply with the UDS policy.

Statement from the NC Medical Board (August 2016)
Current standards of care related to opioid prescribing encourage physicians and physician assistants to take appropriate steps to monitor their patients. Urine drug screening (UDS) is a popular monitoring method. Other methods include regular use of the state’s prescription database to check patient prescription histories, or requiring regular pill counts.

The Board has recently noticed an increase in patient calls in regards to UDS in particular. Concerns raised by patients include overuse of UDS, poor or nonexistent insurance coverage, alleged incorrect interpretation of test results, and poor communication of practice policies related to UDS.

UDS can be a useful tool when administered and interpreted correctly. Licensees are encouraged to fully inform themselves about this monitoring method to ensure its benefit. Presented at right are a few examples of calls related to UDS that have been handled by Board staff in recent months.

Selected Presentations

Drug Testing 2016
J. Paul Martin, MD, DFASAM, Medical Review Officer and Catherine Hammett-Stabler, PhD, DABCC, FACB, Professor of Pathology and Laboratory Medicine, Director, Core Laboratory, McLendon Clinical Laboratories

How: or, Behind the Curtain…
Catherine Hammett-Stabler, PhD, DABCC, FACB, Professor of Pathology and Laboratory Medicine, Director, Core Laboratory, McLendon Clinical Laboratories

Presented at Addiction Medicine 2016

Special thanks to the North Carolina Medical Board for the use of content from the North Carolina Medical Board Forum Issue No. 2 | Summer 2016.