New Patient Urine Drug Screen/Opioid Agreement Protocol

[GatorCHOMPions]

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The practice I joined (HOPD) tests every single new patient and has them sign an opioid agreement before even seeing the physician. The doc who has been there a while before me says he wants to avoid any accusation of bias. I think it's also to not disrupt the clinic flow. Is this common? I have seen it rub certain patients the wrong way, particularly the ones that wouldn't touch opioids with a 10 foot pole. It seems like it makes them feel under unfair scrutiny in some way which I can understand.

Is it reasonable for me to test/sign agreement to only those I am going to prescribe to? What are your policies and procedures? My practice is maybe 10-20% opioids, and the vast majority under 30 MME, so I am not as concerned from a workflow disruption standpoint.

 

[drusso]

The practice I joined (HOPD) tests every single new patient and has them sign an opioid agreement before even seeing the physician. The doc who has been there a while before me says he wants to avoid any accusation of bias. I think it's also to not disrupt the clinic flow. Is this common? I have seen it rub certain patients the wrong way, particularly the ones that wouldn't touch opioids with a 10 foot pole. It seems like it makes them feel under unfair scrutiny in some way which I can understand.

Is it reasonable for me to test/sign agreement to only those I am going to prescribe to? What are your policies and procedures? My practice is maybe 10-20% opioids, and the vast majority under 30 MME, so I am not as concerned from a workflow disruption standpoint.

Welcome to HOPD life. All that U-Tox money is eventually used to subsidize the doc's salary. This is called "Juicing the Vig" on the SOS, the oldest game in town.

 

[PMROralBoards]

It’s a great money maker. I personally refuse to test patients who were not on opioids.

 

[Agast]

Billing for unnecessary testing is a form of fraud, depending on who you ask. If you ask CMS how they feel about paying for Utox on patients who aren’t on opioids and don’t ask for opioids they may be concerned. And whistleblower money is mighty tasty.

 

[lobelsteve]

Would gladly help DOJ in taking down fraudulent practices.

 

[GatorCHOMPions]

Supposedly this colleague said he got in some trouble from patients accusing him of discriminatory UDS and so his response was to screen everyone. I can understand the risk of fraud associated with this practice. It never did seem right, but I was told it's standard practice here. I'll definitely correct it with my patient panel.

 

[Agast]

Supposedly this colleague said he got in some trouble from patients accusing him of discriminatory UDS and so his response was to screen everyone. I can understand the risk of fraud associated with this practice. It never did seem right, but I was told it's standard practice here. I'll definitely correct it with my patient panel.

Does he also offer 30 tabs of hydrocodone to every patient so he does not get accused of discriminating on who gets prescriptions? Bias in medication management has been proven in studies.

 

[lobelsteve]

Couldn't you make the case that it's reasonable to test since not all patients would be telling the truth (about opiates, cannabis, etc)? I mean, in the ER I test almost every female of childbearing age for pregnancy, even if they say "there is no way I could be pregnant." Even if you weren't intending to prescribe them opiates, finding out they were using illicit substances could limit the effectiveness of procedural interventions, etc

You could and I would destroy you in the government document. Testing people for no medical reason is not appropriate.
Also, how does ordering the test change treatment? If not on meds and not going to prescribe meds- why test?

 

[Agast]

So, there is similar drama in ob/gyn. Some practices have a habit of screening all pregnant women for urine toxicology along with the typical STD panel. You could argue that it’s important to identify women who might secretly be abusing drugs during their pregnancy and set up the appropriate counseling. But then you have a ton of angry patients wondering why they have to pay $95 for a UDS when they weren’t informed of or didn’t consent to the test.

 

[lobelsteve]

So, there is similar drama in ob/gyn. Some practices have a habit of screening all pregnant women for urine toxicology along with the typical STD panel. You could argue that it’s important to identify women who might secretly be abusing drugs during their pregnancy and set up the appropriate counseling. But then you have a ton of angry patients wondering why they have to pay $95 for a UDS when they weren’t informed of or didn’t consent to the test.

Changes management at delivery. And screening is appropriate.

 

[PMROralBoards]

So, there is similar drama in ob/gyn. Some practices have a habit of screening all pregnant women for urine toxicology along with the typical STD panel. You could argue that it’s important to identify women who might secretly be abusing drugs during their pregnancy and set up the appropriate counseling. But then you have a ton of angry patients wondering why they have to pay $95 for a UDS when they weren’t informed of or didn’t consent to the test.

Do they also automatically send for confirmatory testing on every sample which the clinic owners also run? I feel that it is much more murky in the pain world.

 

[Ducttape]

treatment of a pregnant woman can significantly impact the fetus and alter your treatment decision making.

that is not the same as doing urine screens, unless you plan on prescribing an opioid and are getting an initial screening UDS.

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confirmation testing should be done on every sample that you order for monitoring for compliance. the dip screens only give a level at a certain cut off point.

case in point, any level of 6-AM is indicative of abuse. tho we are not seeing this much due to the overwhelming prevalence of fentanyl.

 

[Agast]

treatment of a pregnant woman can significantly impact the fetus and alter your treatment decision making.

that is not the same as doing urine screens, unless you plan on prescribing an opioid and are getting an initial screening UDS.

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confirmation testing should be done on every sample that you order for monitoring for compliance. the dip screens only give a level at a certain cut off point.

case in point, any level of 6-AM is indicative of abuse. tho we are not seeing this much due to the overwhelming prevalence of fentanyl.

Sure, but the official guidelines for their own society do not endorse a Utox on every pregnant woman and specifically mention only with consent. This is being added on to the pee test without prior knowledge.

“Routine urine drug screening is controversial. ACOG recommends testing be performed only with the patient’s consent and a positive test not be a deterrent to care, a disqualifier for coverage under publicly-funded programs, or the sole factor in determining family separation.”

Substance Use Disorder in Pregnancy

Obtaining prenatal care, staying connected to the health care system, and being able to speak openly with a physician about drug problems helps improve birth outcomes.

www.acog.org

 

[Ducttape]

i should mention - too late now - that i was focusing on the ER use of urine drug screens.

 

[BoardingDoc]

i should mention - too late now - that i was focusing on the ER use of urine drug screens.

As others have argued already, I'd agree that UDS only serves a purpose if it will change your management. In the ED, I only get a UDS if I have a patient with AMS where it's not immediately obvious that they're intoxicated and I don't have another source... or if they're a psych patient as the UDS is a near universal requirement for placement in virtually all the psych hospitals around me. Same rationale as for getting an hCG in any woman with abdominal pain even if they swear they're a virgin. People lie and it will change management. I've told 2 "virgins" that they were pregnant in the past 10 years.

If someone comes in nodding off without any signs or hx of trauma from EMS and they're covered in track marks... not a whole lot of value in getting a UDS.

 

[Status Sciaticus]

Billing for unnecessary testing is a form of fraud, depending on who you ask. If you ask CMS how they feel about paying for Utox on patients who aren’t on opioids and don’t ask for opioids they may be concerned. And whistleblower money is mighty tasty.

Wouldnt it make sense to screen everyone that you are potentially able to prescribe narcotics to?
IDK how one can justify it if you were never going to prescribe it for that patient, ever.

My rule of thumb is that if youre going to sign an opioid agreement, youre getting a UDS at that visit, and then random ones throughout the year.

 

[Agast]

Wouldnt it make sense to screen everyone that you are potentially able to prescribe narcotics to?
IDK how one can justify it if you were never going to prescribe it for that patient, ever.

.

It’s not in any society guidelines as best practice or standard of care as far as I know but if you can find a source please post it.

 

[lobelsteve]

Wouldnt it make sense to screen everyone that you are potentially able to prescribe narcotics to?
IDK how one can justify it if you were never going to prescribe it for that patient, ever.

My rule of thumb is that if youre going to sign an opioid agreement, youre getting a UDS at that visit, and then random ones throughout the year.

Your wording makes it sound like you’re looking for an excuse to do a urine drug stream to Bill for it. Unless you plan to prescribe opiates to every patient, you see. Either way you’re doing it wrong.

 

[Status Sciaticus]

Your wording makes it sound like you’re looking for an excuse to do a urine drug stream to Bill for it. Unless you plan to prescribe opiates to every patient, you see. Either way you’re doing it wrong.

im looking for a reason to do a UDS to see if the patient is in fact telling me the truth. I've had several patients who said they werent on benzos but then turn up positive for it and other things on UDS, and that has changed my management of those patients.

 

[oreosandsake]

You could and I would destroy you in the government document. Testing people for no medical reason is not appropriate.
Also, how does ordering the test change treatment? If not on meds and not going to prescribe meds- why test?

Just making a case for it but What about other substances that pop up. What if they don’t publicize the THC and the IVDA and the and the…

Medical data guides decision making. Surgeons order A1c and coags even if patient isn’t a known diabetic or coagulopath

 

[Agast]

Medical data guides decision making. Surgeons order A1c and coags even if patient isn’t a known diabetic or coagulopath

You know surgeons who are ordering those on the first office visit prior to talking to the patient?

 

[Ducttape]

Medical data is patient driven and patient specific.

Unless there are clinical indications, then there is no medical indication for testing.

Now if you do a pre chart review and you feel that treating for that specific patient will be altered by a test, you could ask for that test upon arrival at office.

 

[oreosandsake]

You know surgeons who are ordering those on the first office visit prior to talking to the patient?

Local Barrow trained Neurosurgery group expects mri and a1c completed prior to referral to be scheduled

 

[oreosandsake]

I don’t routinely order but I’ve also had patients go through the whole exam and at the last min or after I’ve left the room ask the staff to come get me because they wanted to discuss oxysomazepincontin and don’t want anything else I offered the first 30 min of discussion exam evaluation. Then the UDS becomes an issue and they can’t produce urine because they “just went”

I don’t get a cent for UDS but I think if you want to streamline services it’s not unreasonable. I certainly would look at a Screen if the results were in the emr from a previous hospitalization etc
Also same idea about practices than run PDMP on patients before they even come for evaluation.

 

[drusso]

More testing = better adherence: That's a fact. But, remember for this situation, the real issue is that you have an HOPD-MD who needs to "make her nut" with her employer so the employer has her Juice the Vig on the SOS...

J Pain Res. 2019; 12: 2239–2246.

Published online 2019 Jul 23. doi: 10.2147/JPR.S213536

Increased frequency of urine drug testing in chronic opioid therapy: rationale for strategies for enhancing patient adherence and safety​

David J DiBenedetto,1,2 Kelly M Wawrzyniak,1,2 Michael E Schatman,1,3 Hannah Shapiro,1,4 and Ronald J Kulich2,5

Author information Article notes Copyright and License information PMC Disclaimer

Go to​

Abstract​

Objective​

To determine the average amount of time required to detect opioid aberrancy based upon varying frequencies of urine drug testing (UDT) in a community-based, tertiary care pain management center.

Subjects​

This study was a retrospective analysis of 513 consecutive patients enrolled in a medication management program, receiving chronic opioid therapy between January 1, 2018 and December 31, 2018.

Methods​

Data were extracted from medical records including age at start of the study period, sex, ethnicity, marital status, and smoking status. UDT was performed at each prescribing visit via semi-quantitative immunoassay, and at the discretion of the clinician, a sample was sent for external confirmation using gas chromatography or mass spectrometry testing to clarify questions of inconsistency with patients’ reports or prescribed medications. For purposes of the study, “opioid aberrancy” was defined through inconsistent UDT.

Results​

One hundred and fifteen patients (22.4%) had at least one inconsistent UDT during the study period, and 160 (2.8%) of all UDTs were inconsistent. At this rate of inconsistency, it was determined that with monthly screening, it would require up to 36 months to detect a single aberrancy, and semi-annual testing would require as long as 216 months to detect an aberrancy.

Conclusions​

More frequent UDT can be helpful in terms of earlier detection of opioid aberrancy. This has significant implications for helping avoid misuse, overdose, and potential diversion. Furthermore, early detection will ideally result in earlier implementation of treatment of the emotional and behavioral factors causing aberrancy. Such early intervention is more likely to be successful in terms of reducing substance misuse in a chronic pain population, providing a higher degree of patient adherence and safety, as well as producing superior overall patient outcomes. Finally, economic benefits may include substantial savings through avoidance of the necessity for drug rehabilitation and the empirically established higher costs of treating opioid misuse comorbidities.

Keywords: urine drug testing, frequency, opioid safety, economic benefits

 

[lobelsteve]

I don’t routinely order but I’ve also had patients go through the whole exam and at the last min or after I’ve left the room ask the staff to come get me because they wanted to discuss oxysomazepincontin and don’t want anything else I offered the first 30 min of discussion exam evaluation. Then the UDS becomes an issue and they can’t produce urine because they “just went”

I don’t get a cent for UDS but I think if you want to streamline services it’s not unreasonable. I certainly would look at a Screen if the results were in the emr from a previous hospitalization etc
Also same idea about practices than run PDMP on patients before they even come for evaluation.

PDMP is free.
UDS is costly for patient, the system, and can be a pure profit machine for the doc.

 

[Ducttape]

Again the useless diversion to HOPD.

Does not further the discussion.

Those who are requesting mri etc before seeing the patient are not ordering them. They are requesting the referring doctor order these studies.

You should not be ordering any study until you have an established relationship with that patient - or by default you have already set up such a relationship before seeing them.

 

[lobelsteve]

UDS should ordered prior to initiating opiates in patients you will prescribe to if UDS, ICAT, outside records appropriate, and they are undergoing some type of multimodal; care. UDS also ordered for monitoring. Doing it for other reasons gives the appearance of fraud.

 

[drusso]

Again the useless diversion to HOPD.

Does not further the discussion.

Those who are requesting mri etc before seeing the patient are not ordering them. They are requesting the referring doctor order these studies.

You should not be ordering any study until you have an established relationship with that patient - or by default you have already set up such a relationship before seeing them.

Your bias is showing...


The practice I joined (HOPD) tests every single new patient and has them sign an opioid agreement before even seeing the physician. The doc who has been there a while before me says he wants to avoid any accusation of bias.

 

[lobelsteve]

Your bias is showing...


The practice I joined (HOPD) tests every single new patient and has them sign an opioid agreement before even seeing the physician. The doc who has been there a while before me says he wants to avoid any accusation of bias.

If you’re being serious, this is one of the stupidest things. I’ve read on SDN. If I were working with the patient’s attorney, we would sue the pants off the dock in the hospital. You have an inherent duty to prescribe once you do a UDS and have a contract in place, especially if the patient is on opiates from a primary care when you take the referral. You have no way out of this contract as you have the obligation, mostly because you never met with the patient to discuss what it entailed.

 

[Status Sciaticus]

PDMP is free.
UDS is costly for patient, the system, and can be a pure profit machine for the doc.

I didn't know drug dealer transactions got updated on the PDMP. Would definitely make my life easier.

If you’re being serious, this is one of the stupidest things. I’ve read on SDN. If I were working with the patient’s attorney, we would sue the pants off the dock in the hospital. You have an inherent duty to prescribe once you do a UDS and have a contract in place, especially if the patient is on opiates from a primary care when you take the referral. You have no way out of this contract as you have the obligation, mostly because you never met with the patient to discuss what it entailed.

Why? You dont have a duty to do that if you are screening patients based on UDS. I'm not taking patients who are on benzos or are taking illicit drugs, and getting a UDS prior to signing the contract gets me out of the scenario you just described.

 

[clubdeac]

I think having every patient sign an opioid agreement sounds terrible. You’re pretty much married to them for opioids after that. Anyone else could refuse them opioids saying that they specifically have an exclusive agreement with you, go back to your pain doctor. You’re pretty much committing to to being every patients pill pusher whether you like it or not, barring a dirty screen

 

[Ducttape]

Your bias is showing...


The practice I joined (HOPD) tests every single new patient and has them sign an opioid agreement before even seeing the physician. The doc who has been there a while before me says he wants to avoid any accusation of bias.

once that patient signs an opioid agreement, the physician is obligated to his end of the agreement - prescribing opioid medications.

2 way street.

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if you screen before you see the patient, you have the duty to prescribe as you have predetermined that the patient would be appropriate for opioid therapy. now you say "hold on, i was only screening before." any legal person would counter that an agreement is essentially a form of a contract and you as the person presenting have an obligation to the patient - ie prescribing.

if you are screening based on your clinical assessment that opioids may be an option, then that is a legitimate use of the UDS.

for COT, i always see the patient, discuss the treatment agreement, then obtain the UDS. they come back to review the UDS and then the treatment agreement is signed and appropriate medication will be prescribed. i cant tell you the number of times the patient suddenly cannot produce a urine sample or are suddenly running late and can they come back later (because they forgot their fake urine or forgot their whizzinator et al,)