Drug Testing when prescribing controlled substances

[Psychobabbling]

This is something I wanted to look more into, so I decided to start here. Is there specific protocol for tox screens, how often, etc. I only ask because I see different things going on in the community.

At community mental health clinics that take medicaid - I see people wanting tox screens monthly when prescribing a controlled substance

At clinics that take private insurance - I see people getting Klonopin, Adderall, etc without ever being tox'ed, or rarely.

I'm not accusing one population of misusing their scripts or not, just wondering if there were any guidelines/EBM on the issue.

Thanks!

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[JesusSaves]

DEA guidelines for schedule II substances is to test every month. It is not required, though. It is really up to the doctor.

 

[PikminOC]

DEA guidelines for schedule II substances is to test every month. It is not required, though. It is really up to the doctor.

 

[TexasPhysician]

The problem with tox screens is that quality is poor. You will often have to send out for confirmatory tests. For that reason, I use them either selectively for suspicious cases or as a form of cya to say it was done.

I've actually had arguments with labs over Clonazepam. They argue it will test positive under benzos, and I don't need confirmatory tests to rule out false negatives. If so, I have a 100% diversion rate in my clinic.

 

[F0nzie]

I've actually had arguments with labs over Clonazepam. They argue it will test positive under benzos, and I don't need confirmatory tests to rule out false negatives. If so, I have a 100% diversion rate in my clinic.

That's weird. Clonazepam is expected to test negative with standard UDS because it is not metabolized to Oxazepam. You would need to send out a test that specifically detects Clonazepam.

 

[F0nzie]

A random UDS may be more effective than a scheduled UDS at picking up active drug abuse. However it's never truly random if it's scheduled during an office visit...

Consider false positive ie. + opiates with poppy seeds. Also contaminants, substitution, etc.

I agree with TexasPhysician in using UDS for suspicious cases ie. drug seeking behaviors, repeatedly losing rxes, presenting high, etc.

If they have an hx of a substance use disorder and you are prescribing a controlled substance consider random UDS for safety reasons as well as legal protection.

 

[milesed]

Our state law is to test before any controlled med is rx'd and repeat randomly if over 18. We do it at least yearly. I think monthly is way to costly. UDS for kids is prn only.

 

[birchswing]

All very interesting. I've been prescribed benzos for 17 years and never have done a drug test. I have no doubt it would come up positive for benzos. I wish the state law had been to drug test before prescribing--not because I have ever taken any drug other than exactly as prescribed nor have I ever taken any recreational drug, but because it might have made the psychiatrist have to jump through a hoop that would have made prescribing such a drug more of a hassle and made him more likely to be a little creative in his thinking, rather than jumping to long-term benzo therapy for a 15-year old with no psychological work up or physical examination. If anything it seems like such a law is a good impediment to lazy prescribers, like the equivalent of a waiting period for buying a gun. A person with a legitimate purpose for purchasing a gun doesn't stress over waiting 7 days. An impetuous person does.

 

[milesed]

The law in my state doesn't mandate what has to be done with the results. It was aimed at preventing doctor shopping and other things like this got added by the state medical board as they interpreted how they thought the law should be implemented. It's interesting how many are misusing meds you'd never suspect. The drug tester we use can show not only +/- but also exactly WHICH benzo, stimulant, pain med you are positive for (if selling your med or taking someone else's).

I see mostly kids so am not required to test them. We usually give them a second chance as it opens a dialog about dual diagnosis issues.

 

[Theuniqueldy]

This is something I wanted to look more into, so I decided to start here. Is there specific protocol for tox screens, how often, etc. I only ask because I see different things going on in the community.

At community mental health clinics that take medicaid - I see people wanting tox screens monthly when prescribing a controlled substance

At clinics that take private insurance - I see people getting Klonopin, Adderall, etc without ever being tox'ed, or rarely.

I'm not accusing one population of misusing their scripts or not, just wondering if there were any guidelines/EBM on the issue.

Thanks!

 

[Attending1985]

Highly recommend random uds and pill count. Have discovered numerous people abusing med/diverting med/abusing other substances. We use a compliance drug assay which is very accurate. None of these people had any evidence of problems on their pdmp.

 

[NITRAS]

Taking an old narcotic while under the care of a new pain doctor is not taking your meds as prescribed, even if the old prescription was legally obtained.

Our hospital screen UDS are terrible, but the confirmatory tests are quite good, but they take a while to get back to us (usually after they leave the hospital).

 

[milesed]

Our state medical board requires initial, yearly and random testing. It's very nice to blame it on "the state" as well as when I find something interesting in the results. We have a lab that does mass spec and looks for prescribed meds also.

 

[SeniorWrangler]

This varies from state to state, but "never" is probably the wrong answer no matter where you are.

 

[VA Hopeful Dr]

Narcotics, every visit. Everything else at least yearly, q6M if I'm even slightly leery of the patient.

 

[whopper]

I find it overkill to test someone monthly if they've been clean over 1 year.
Also several places charge ridiculous amounts of money for a urine drug test. E.g. a typical drug test you can buy OTC for $25 can be bought in bulk for $10 but many private labs charge around $150 for a drug test using this very conventional method. Then some places rip you off by only doing the $800 gas chromatography/Star Trek transporter/replicator type test that usually is not needed.

 

[NickNaylor]

It’s interesting to see the different practice habits.

As far as I’m aware, there isn’t a required screening schedule dictated by the medical board in my state. As a general rule I very rarely get a UDS, even for patients that are on controlled substances. For my patients on long-term benzos, I’m already actively working to taper them off, so I’m not sure that a UDS is going to change my management in a meaningful way. I have one patient on my panel on stimulants who also falls in the long-term benzo category, so same deal there.

I just don’t see the value in these situations. I check our prescription monitoring system prior to every visit, and I have been very clear with my patients that receiving controlled substances from any other provider will result in an immediate taper or, if they prefer, immediate discontinuation of prescriptions from me and they can continue to get them from the other provider they received a prescription from. I’m not sure that it’s meaningful to me to know that someone is smoking pot. Hell, a good number of benzo-receiving patients are on concomitant opioids (ugh), so that would require a GC-MS for confirmation if I was concerned about illicit opioids, and that’s just a hassle.