Illicit positives and procedures

[Laryngospasm]

Curious to know what everyone’s feelings are regarding positive drug screens for things like cocaine or meth when the patient has a procedure scheduled and you are NOT writing them any medications. Do you cancel or do it? And what is your rationale.

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[deleted131481]

I will not do the procedure if it is recent/active use. I may consider if they are active in rehab. If they aren't concerned enough to stop or get help, I don't feel like the shot is going to be worthwhile. If drug use is remote, I will do it, but I don't retest either. THC I'm ok with proceeding.

On a similar note, will you all prescribe non-controlled medication to those with known drug use? I used to but am starting not to now.

 

[Laryngospasm]

I do prescribe non controlled to people with known drug use. Curious to hear what everyone else does.

 

[gaseous_clay]

I do prescribe non controlled to people with known drug use. Curious to hear what everyone else does.

Yeah I do that all the time. No law against that.

 

[Ferrismonk]

If cocaine/meth/etc, no medications or procedures.

I dont want them to overdose and bleed out on my NSAIDS or to die mysteriously after my CESI and the family sues me instead of blaming sweet little Timmy's raging coke habit.

 

[lobelsteve]

Why are they getting a urine drug screen if they’re not on Rx?

 

[TheLoneWolf]

Why are they getting a urine drug screen if they’re not on Rx?

This

Would test anyone with suspected or confirmed IVDA and refuse to perform elective procedures if positive. Dont want blame for raging endocarditis to be put on my procedures.

 

[Laryngospasm]

We test all new patients

 

[Agast]

It’s not worth the $200 to do the injection on someone untrustworthy. When you stick your needle in someone you have some ownership over their pain in the next 48 hours whether you like it or not.

 

[lobelsteve]

If you suspect substance abuse you should refuse to perform the procedure. You should also notify the prescribing physician if patient is on Rx. If they are just on street drugs, have the discussion regarding getting treatment.

If you own a UDS lab and test patients not being prescribed- that does not make clinical sense and looks to be financially motivated. How would getting that test change your treatment?

Smells bad, looks bad.

If my mom came to you for an epidural and you asked for a UDS, fingers up and bye bye. I would encourage her to report that behavior.
Why not get a baseline EKG on every patient pre-procedure? Why not get an MRI on every patient prior to MBB or SIJ?

 

[Laryngospasm]

It’s been a hospital policy since I started. I have no financial interest in it and the other old pain guy insists on it. I just started a new job not too long ago and am still trying to get everything settled. My old practice we only tested when prescribing. I’m not really asking for moral advice on testing. I’m just curious if you guys cancel procedures when you get a positive. I appreciate the advice.

 

[Ferrismonk]

If you suspect substance abuse you should refuse to perform the procedure. You should also notify the prescribing physician if patient is on Rx. If they are just on street drugs, have the discussion regarding getting treatment.

If you own a UDS lab and test patients not being prescribed- that does not make clinical sense and looks to be financially motivated. How would getting that test change your treatment?

Smells bad, looks bad.

If my mom came to you for an epidural and you asked for a UDS, fingers up and bye bye. I would encourage her to report that behavior.
Why not get a baseline EKG on every patient pre-procedure? Why not get an MRI on every patient prior to MBB or SIJ?

Generally agree, but fwiw there is a push in the primary care world to screen everyone at baseline along with the routine labs.

 

[Laryngospasm]

I don’t agree with testing for no reason but a screening test initially is not unreasonable.

 

[Ligament]

It is not worth getting medically and legally intertwined with a drug addict. They will bring you down just like everybody else in their life. They cannot follow federal law they sure as hell cannot follow your pre or post op instructions. Is it worth it for $200? Not for me.

 

[SommeRiver]

No urine if no controlled Rx IMO.

 

[deleted131481]

I don't routinely check UDS, but sometimes they have it available from PCP or hospital admission. Most won't come back to see me when I recommend rehab and PT. If they actually go through with it, I'll consider procedures or non-controlled meds.

 

[paindoc007]

I don’t agree with testing for no reason but a screening test initially is not unreasonable.

I’ll just throw this out there. You’re probably writing too much opioids if you’re screening everyone. Aka most of your patients get opioids at some point in their treatment with you so baseline uds useful when you start them sort of thing. If a small % get started on chronic opioid analgesia, baseline uds for everyone makes no sense. Just food for thought

 

[Laryngospasm]

I’ll just throw this out there. You’re probably writing too much opioids if you’re screening everyone. Aka most of your patients get opioids at some point in their treatment with you so baseline uds useful when you start them sort of thing. If a small % get started on chronic opioid analgesia, baseline uds for everyone makes no sense. Just food for thought

I appreciate the input. I don’t write opioids for many people. And I don’t have one single patient on more than 40mme etc for a couple cancer patients. This is a policy from the preexisting pain doc and the current other pain doc.

 

[au bon pain]

I've worked at several places that did urine drug screens. Generally speaking, they are terrible tests and mostly wish they didn't exist. Sensitivity and specificity is often abysmal. Tons of Rx get missed. Many illicits will never be detected. And there are tons of potential false positives: motrin can test + for barbs, cipro can test + opiates, benadryl can test + for both pcp and methadone, and the list goes on.

If I'm really concerned about illicit use in patients but don't see obvious evidence (needle tracks, pt presenting high, etc) then I still listen to the voice in my head saying I still don't want to stick a needle in them, decide that risks>benefits, and cancel. While imperfect, I suspect it leads me down the right path more frequently than following a standard uds.

 

[Orin]

I explicitly don't get a UDS on intake on most cases so I can use it as a reason to delay prescribing controlled substances, although I will drizzle some a gabapentinoid without a UDS.

I don't inject that many people, but I would say that most of them have had a UDS if they get to procedure stage. I would feel comfortable injecting someone who tested clean with a prior h/o abuse. I wouldn't inject anyone actively abusing illicits but THC I do let slide.

 

[SommeRiver]

Why would anyone get a UDS on intake for the sake of an intake UDS?

This makes zero sense to me, nearly to the point of my considering making an argument about overreach. As in, a clever wordsmith may be able to spin this as an invasion of privacy.

You have no justification to UDS someone on intake for the simple reason you're a pain doctor.

Damn I live and practice in a different world than some of yall...

No such thing as a UDS to support the safety of a procedure either...That's crazy.

 

[Ducttape]

I see a lot of patients who have UDS from previous ER visits.

it is a tricky issue, because clearly these patients are not getting UDS from me.

1. I may consider prescribing some non-opioid meds, but shy away from prescribing, and ask the PCP to consider. obviously no controlled substance, no gabapentin, and only limited muscle relaxants.

2. in terms of procedures, most of these patients testing positive for cocaine and meth do not want them. I do not suggest them, either. if they do request, then we start talking about the positive UDS and whether they are actively using, and I offer them substance abuse counselling and suggest that they have bigger problems than can be fixed with an injection.


"No such thing as a UDS to support the safety of a procedure either...That's crazy."
well, there are always shades of grey. semantically, it seems appropriate for ortho or spine surgeons to screen for nicotine in their fusion or TKR patients...

 

[myrandom2003]

Why is everyone anti-gabapentin? is it REALLY that abused?

Also if you are not prescribing and they have a positive UDS from somewhere else, and you are worried about infection, why not pre treat them with a shot in the arm of abx before the procedure and send them home with some.

Have a hot radic and abusing cocaine shouldn't have to exclude each other. I mean being ok with THC which is still illegal and smoked most often can still have infection issues in the lungs and a weakened immune system. I think thats been proven by the cardiology folks.

so being ok with some drug use and not others doesnt make sense to me either.

I still do the procedure. I talk to them, i get blood work, i prescribe abx. and i follow up sooner than usual.

this is out of the 10 people i have.

 

[NOSfan]

It’s been a hospital policy since I started. I have no financial interest in it and the other old pain guy insists on it. I just started a new job not too long ago and am still trying to get everything settled. My old practice we only tested when prescribing. I’m not really asking for moral advice on testing. I’m just curious if you guys cancel procedures when you get a positive. I appreciate the advice.

If you order the test, you are obligated to f/u and treat accordingly. Therefore, the patient should be referred to an Addictionologist.

Meth/Cocaine positive = NO procedures

 

[myrandom2003]

just a random poll question, how many of your UDS +patients for anything other than THC are medicaids versus commercials versus medicare?

I find that most of the + are the caids, and some medicares. not a lot of commerical (though those tend to be the cocaines for me)