Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4053 — Clinician Response to Aberrant Urine Drug Test Results among Patients Initiating Opioid Therapy for Chronic Pain

Lead/Presenter: Erin Krebs
All Authors: Morasco BJ (VA Portland Health Care System) Krebs EE (Minneapolis VA Health Care System) Zamudio J (VA Portland Health Care System) Adams MH (VA Portland Health Care System) Hyde S (VA Portland Health Care System) Dobscha SK (VA Portland Health Care System)

Objectives:
Opioid treatment guidelines recommend urine drug testing (UDT) for patients who are initiating prescription opioids, but it is unclear how clinicians respond to aberrant UDT results. The purpose of this study was to examine the frequency of strategies used by clinicians to address aberrant UDT results.

Methods:
In a national cohort of VA patients with new initiations of opioid therapy for chronic pain, we identified a random sample of 100 patients who had aberrant positive UDTs (results positive for non-prescribed/illicit substances) and 100 who had aberrant negative UDTs (results negative for prescribed opioids). We examined patient medical records for subsequent changes in opioid prescribing for 12 months following UDTs.

Results:
The most common aberrant positive UDT results were cannabis (42%), a non-prescribed benzodiazepine (26%), or opioid (11%). Of patients with an aberrant positive UDT, 52% had a change in treatment to reduce opioid-related risk. The most common strategies were increased frequency of UDT (24%), opioid discontinuation (16%), referral for addictions treatment (5%) or mental health (10%), or some "other" strategy (most common was signing an opioid treatment agreement; 24%). Of patients with an aberrant negative UDT, 65% had an opioid-related treatment change. The most common risk reduction strategies in this group were signing an opioid treatment agreement (54%) or increased frequency of UDT (35%); few patients were discontinued from opioids (4%) or transitioned to another opioid (2%). Across both groups, of clinicians who planned a change in opioid prescribing due to aberrant UDT, 96% completed at least one treatment change. Aberrant UDT results were frequently perceived as due to inadequate pain management, and 65% of patients had subsequent changes in non-opioid strategies for managing pain.

Implications:
In this study, 58.5% of clinicians enacted changes to reduce opioid-related risk following an aberrant UDT. Strategies for reducing opioid-related risk differed based on whether the UDT was positive for non-prescribed/illicit substance or negative for the prescribed opioid.

Impacts:
Identification of an aberrant UDT among patients initiating opioid therapy is an opportunity to modify treatment to reduce opioid-related risk and improve pain care. Prospective research is needed to examine the effectiveness of strategies for reducing opioid-related risk.