Ordering Urine Drug Screen

[xaelia]

You know you've done this/been asked to do it ....

Is it acceptable to order a urine drug screen on a patient without their knowledge/consent?

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[Doctor Bob]

I order a UDS without asking when there's a medical reason for me to need to know. I don't run every lab test I'm planning to order past the patient to get their approval. The inherent assumption in the doctor/patient relationship is that anything I order is being done toward the goal of making them better.

I don't do them when the PD asks me to in order to make their case easier, or when a parents asks me to test their mid-teenager because they think they smelled MJ in their room, etc, etc, etc... Non-medically necessary situations.

 

[Apollyon]

I order a UDS without asking when there's a medical reason for me to need to know. I don't run every lab test I'm planning to order past the patient to get their approval. The inherent assumption in the doctor/patient relationship is that anything I order is being done toward the goal of making them better.

I don't do them when the PD asks me to in order to make their case easier, or when a parents asks me to test their mid-teenager because they think they smelled MJ in their room, etc, etc, etc... Non-medically necessary situations.

This was exactly my response. And, yes, I've done it.

 

[Birdstrike]

I agree that it's best to stick to tests that are medically indicated. Otherwise send them to Walgreens for their 12-panel pee cup, which is basically the same test for hundreds of dollars cheaper:

http://www.walgreens.com/store/c/at-home-drug-test,-12-panel/ID=prod4021948-product

(Have them stop by the dollar store for a $1 preg test while they're at it.)

Remember, ED dip cup UDS's have very high false negative/false positive rates, unless you send them out for a GC/MS confirmation (about $1,000-$1,500) which you're not going to do, ever. In general, they give you little if any information relevant to ED care that wouldn't be present in history, a basic toxindrome, or that won't respond to narcan and/or supportive care.

If you do find some medical reason to order an ED UDS (hospitalists love these tests) you're covered under implied consent along with all the consent to treat forms signed upon arrival.

As far as being told by cops to get a UDS, that's a little tougher. I might tell the cop it's not medically needed and not a forensic level or court worthy test. If a cop is still demanding/insisting that I order it, then I'd order it. I think it makes sense to do what guys with guns demand.

But I'd also put that in the chart ("UDS demanded/ordered/required by PD") so that if there's some bogus lawsuit coming back (not likely, but possible) it makes it clear who made the push for it.

If a parent demands one on a minor, I suppose you have to balance the patient satisfaction vs ED throughput issues, while trying to educate them on the test inaccuracy and massive bill they're going to get for a drug store test. Should you ever force cath a teenager who's refusing one, because of a parental demand? Definitely not.

The only exception to all of this is if the patient is Xaelia. If so, the drug test should definitely be ordered. Stat.

 

[Zebra Hunter]

When is a UDS medically indicated? Maybe a patient that is acutely psychotic without a known psych diagnosis?

 

[xaelia]

I order a UDS without asking when there's a medical reason for me to need to know.

In theory, couldn't you just ask them?

... and wouldn't then the ordering of a test to confirm or refute their history be mildly offensive?

I figure, if a patient is being charged for various tests, I ought to be a little less vague on what and why I'm ordering things. I don't go crazy about basic bloodwork that's a few bucks here and there at insurance negotiated rates, but once I get up into stuff that's >$100 it seems reasonable to at least mention I'm ordering it discuss its value with a patient.

Just mildly annoyed by how many times I see such a useless, not-cheap test ordered or requested 'round here without the patient being involved ....

 

[dotcb]

Patients either sign a general consent for treatment or emergency consent is implied if they are unable to.

I rarely tell patients a great degree of detail about the tests that I'm ordering on them. I think it's fine to order an indicated test, unless the patient specifically mentions that they do not want something that you're planning on doing.

I used to be really dogmatic about not ordering urine drug screens when I came out of residency. Turns out the test is very cheap at my hospital, and I've found that it often does contribute to the management of patients. So I order them not infrequently.

Ex. AMS NOS

 

[Doctor Bob]

In theory, couldn't you just ask them?

... and wouldn't then the ordering of a test to confirm or refute their history be mildly offensive?

If the only reason you're ordering a UDS is to catch the patient in a lie or something similar, that may be problematic.
I mean... I check a CBC even if the patient tells me they aren't anemic and have no history of it. I check LFTs even if the patient says they have no history of liver problems. Etc, etc, etc. I check them because they add or remove items from my differential.

Unfortunately patients lie. Either intentionally or unintentionally. I check pregnancy tests on female patients even if they *insist* there's no way they could be pregnant. I check UDSs on patients if their history or symptomatology suggests a possibility of illicit drug use that could be relevant to me treating them. If it's not relevant, then I don't check it even if there's a chance they might be lying to me. Broke your ankle? I don't care if you were high when it happened. Having a hypertensive emergency? Yea, I care if you've also got cocaine in your system.

As for telling them the list of things I'm ordering...
I don't work at McHospital. Patients don't get to pick and choose what they get. Either they trust in my intentions/ability to help and make them better, or this doctor/patient relationship is in rather dire straits. By coming in they have declared that what they believe is happening is an emergency (to them) and as such I will do whatever I feel is necessary to get to the bottom of it. Sometimes that's a lot, other times it's very little. But the path to the diagnosis is mine to determine.

 

[Hair Police]

I have ordered a UDS on patients without their knowledge when it was medically indicated. AMS is a good example. I would not order it on a person when not indicated - like Xaleia mentioned, if it's tangential to the presenting complaint and they tell me they smoked crack two days ago, there's no need for a confirmatory test. What hypothesis am I testing? Because if they admit to substance abuse, I just take them at their word. As a result I rarely order UDS.

The parents or PD bringing someone in for a given test - I don't order it unless it is medically indicated and I don't share the results without the patient's permission.

The one exception is emergency petitions, which means someone has filed a petition with a judge asking for the police assistance in bringing a person (usually a parent, sibling, or cousin) into a hospital for psychiatric evaluation. Usually the paperwork describes dangerous SI/HI/psychotic behavior. In that case, UDS is a part of the standard screen the psych evaluators want, and can be taken without consent (I have never done this). But the results are only shared within the treatment team.

I've had discussions with our psych teams on this point, and a lot of it revolves on the fact that patients can't be 'intoxicated', sign a voluntary admission order, and have it hold up in court. Forget the fact that some daily drinkers live with BACs north of 200...

 

[Janders]

First, I check them when I feel they are medically called for. I don't ask specific permission. I can't say I order them often... but some cases of altered mental status, without OBVIOUS hx/toxidrome, can be helped by the UDS. These people are altered, and I assume implied consent for emergent treatment. The treatment of an agitated manic patient with florid psychosis may be different with a +cocaine.

Conscious patients who I STILL get a UDS on? Two uncommon come to mind... (1) Recurrent cocaine associated chest pain; if the patient denies cocaine use I may STILL want a UDS, as some of these patients are not truthful with me, and I do believe the +cocaine matters medically. (2) Cyclical vomiting syndrome... I believe in cannabinoid hyperemesis, and again it is useful to have a +MJ in a patient who denies use, just so I can explain the concept of the syndrome to them.

Then there is the entire subgroup of patients who are in the ED for psych/dual diagnosis placement. Often UDS is obtained on THESE patients purely due to the demands of the eventual accepting psychiatrist (a can of worms we don't have to open on this thread). These patients I do tell precisely why we are testing their urine, as I personally do not usually find these results useful, and am getting them at the behest of another physician.

 

[WilcoWorld]

I have to transfer a lot of Psych admission, and the receiving facilities often insist that a UDS be performed prior to transfer. The UDS is also part of our standard Trauma Protocol. I think that both of these policies are idiotic, yet I have never obtained consent for either indication.

Damnit, now you've got me thinking That can be dangerous.

 

[Rendar5]

I only order UDS when I'm worried about a medical disorder related to cocaine use, or something that's going to be a psych admission. In terms of searching out drug seeking cases on someone I suspect is abusing, did it once to catch them in a flat-out lie and the other time I did it was because I believed them and knew the admitting team wouldn't so I got it to get a negative test (they took absoluately no medications a all, so not worried about false positive) t make sure their case was taken seriously.

 

[Birdstrike]

I only order UDS when I'm worried about a medical disorder related to cocaine use, or something that's going to be a psych admission. In terms of searching out drug seeking cases on someone I suspect is abusing, did it once to catch them in a flat-out lie and the other time I did it was because I believed them and knew the admitting team wouldn't so I got it to get a negative test (they took absoluately no medications a all, so not worried about false positive) t make sure their case was taken seriously.

Some opiates like fentanyl won't show up on dipstick UDS. Don't forget false negatives. These tests suck. They're like telling a patient who is or isn't cheating on them with an STD test.

 

[Daiphon]

Some opiates like fentanyl won't show up on dipstick UDS. Don't forget false negatives. These tests suck. They're like telling a patient who is or isn't cheating on them with an STD test.

Nitpicky, but fentanyl isn't an opiate - which is why it doesn't show up.

Opiates = naturally occurring opioids (morphine, codeine, thebaine)

Opioids = anything reversible by naloxone (old definition was anything with mu/kappa activity)

The UDS is targeted at looking for monoacetylmorphine, so only drugs undergoing this particular flavor of metabolism can be detected. Synthetics like fentanyl, demerol, or methadone won't trip a positive.

Semisynthetics such as hydrocodone & hydromorphone typically do so will usually piss positive. Oxycodone does too, but all the extra crap stuck on the molecule prevents UDS binding and thus appears negative.

tl;dr - standard UDS sucks for anything short of cocaine/MJ.

 

[Rendar5]

Some opiates like fentanyl won't show up on dipstick UDS. Don't forget false negatives. These tests suck. They're like telling a patient who is or isn't cheating on them with an STD test.

Dilaudid is the abusable opiate of choice in Florida so not worrying about it. But honestly that's 2 times in 3 years that I've used it for opiate answers, and once was to prove to the inpt team that it was negatve

 

[ccfccp]

I basically only order them for AMS/coma of uncertain origin and for psych placement (our psych receiving facilities require them).

 

[shookwell]

As far as being told by cops to get a UDS, that's a little tougher. I might tell the cop it's not medically needed and not a forensic level or court worthy test. If a cop is still demanding/insisting that I order it, then I'd order it. I think it makes sense to do what guys with guns demand.

But I'd also put that in the chart ("UDS demanded/ordered/required by PD") so that if there's some bogus lawsuit coming back (not likely, but possible) it makes it clear who made the push for it.

If a parent demands one on a minor, I suppose you have to balance the patient satisfaction vs ED throughput issues, while trying to educate them on the test inaccuracy and massive bill they're going to get for a drug store test. Should you ever force cath a teenager who's refusing one, because of a parental demand? Definitely not.

I would never order a test just because the police want it. Even if they have a warrant or judge's order, my job is to take care of the patient and I think it is unethical to draw bloodwork or send a blood test for the police. Even when the law says that the police can forcibly take blood I will refuse to do it. This comes up when the cops bring in someone who they think is drunk but refuses a breathalyzer. I discharge the patient (assuming there are no other issues) and ask them to leave.

Urine drug screens are pretty unreliable and useless tests in general. They are only useful to get psychiatrists or surgeons to accept patients. Cocaine is the only one that occasionally has some clinical utility.

 

[TooMuchResearch]

I do enjoy when the consultant/admitting service asks me if I ordered a drug screen in an obviously high on something individual with an unrelated complaint. "She seems kind of sleepy and weird in there. Did you order a drug screen?"

 

[xaelia]

Interestingly, I posed this same question to my 4,600 followers on Twitter:


Not many responses, but the general gist – probably unethical, with exceptions in the few patients where even a usually useless test could remotely be considered to have some clinical value. When it's being used inappropriately – and patients are being charged for it – it should at least be explicitly mentioned.

 

[Birdstrike]

Interestingly, I posed this same question to my 4,600 followers on Twitter:


Not many responses, but the general gist – probably unethical, with exceptions in the few patients where even a usually useless test could remotely be considered to have some clinical value. When it's being used inappropriately – and patients are being charged for it – it should at least be explicitly mentioned.

Just curious: why is this such a hot button issue for you?

 

[wholeheartedly]

Nitpicky, but fentanyl isn't an opiate - which is why it doesn't show up.

Opiates = naturally occurring opioids (morphine, codeine, thebaine)

Opioids = anything reversible by naloxone (old definition was anything with mu/kappa activity)

The UDS is targeted at looking for monoacetylmorphine, so only drugs undergoing this particular flavor of metabolism can be detected. Synthetics like fentanyl, demerol, or methadone won't trip a positive.

Semisynthetics such as hydrocodone & hydromorphone typically do so will usually piss positive. Oxycodone does too, but all the extra crap stuck on the molecule prevents UDS binding and thus appears negative.

tl;dr - standard UDS sucks for anything short of cocaine/MJ.

I know this is older, but since the thread got bumped I just wanted to clarify that this is highly variable among the different assays used for urine drug screens.

So what the lab at your institution tests for, the metabolites or synthetics that can be detected, and the thresholds for detection can be very different than the lab at the hospital down the road and very different than dipstick based screens. So be careful generalizing.

 

[Daiphon]

I know this is older, but since the thread got bumped I just wanted to clarify that this is highly variable among the different assays used for urine drug screens.

So what the lab at your institution tests for, the metabolites or synthetics that can be detected, and the thresholds for detection can be very different than the lab at the hospital down the road and very different than dipstick based screens. So be careful generalizing.

It's not a generalization. Though I agree that different hospitals may have different tests.

If you have a UDS that will pick up oxy or the synthetics, then that's because your hospital has purchased either a stand-alone assay for that particular opioid or a more expensive UDS cartridge that includes them.

What is considered the "opiate" screen is an immunoassay targeted at morphine metabolites; and my original post stands.

-d

 

[wholeheartedly]

My post was intended to be a general FYI/caution to folks reading.

Though I agree that different hospitals may have different tests.

Yeah, that was part of my point.

You state

the UDS is targeted at looking for monoacetylmorphine, so only drugs undergoing this particular flavor of metabolism can be detected. Synthetics like fentanyl, demerol, or methadone won't trip a positive.

I quoted your post, but I was referring to that and just general FYI to people posting that "urine drug screens don't test for x, y, z"

This part of my point

So what the lab at your institution tests for

was that "urine drug screens" are essentially a panel that can have all kinds of things on them. Obviously with a cartridge or dipstick set up, you're limited to what's available on that, but if you're running them on a chemistry analyzer like bigger places often do you can essentially include whatever you want. If there's something providers want and aren't getting that would be helpful, you can probably get it. Our institution offers several "urine drug screens" we've got one for the ED, one for the pain clinic, etc. So the point I was attempting to make with that for the general audience of the forum was to be careful generalizing that what's on a screen at one place is the same at another, or that a provider can't request expanded options if needed. So saying a urine drug screen won't pick up fentanyl isn't necessarily true. Methadone also seems to be getting more popular for instance.

With respect to the "opiate" assay in particular...

If you have a UDS that will pick up oxy or the synthetics, then that's because your hospital has purchased either a stand-alone assay for that particular opioid or a more expensive UDS cartridge that includes them.

What is considered the "opiate" screen is an immunoassay targeted at morphine metabolites; and my original post stands.

-d

While these immunoassays are targeted at morphine metabolites as you've said, they cross react like crazy with other substances (most major reagent manufacturers list a couple dozen).

My intended caution was: which of these substances and the concentration thresholds of these other substances needed to trip the opiate screen positive varies greatly by reagent manufacturer because they each develop their own antibodies (proprietary issues and all that). Which is why I stated that people (in general, not just you specifically) need to be careful not to generalize that just because x metabolite, or semi-synthetic did or did not show up on the "opiate" part of the screen, that it's the same elsewhere. In that case I'm not referring to any instance of add-on options to a regular opiate immunoassay.

For instance you state that if" your screen picks up Oxy" it must be because there's either a standalone assay or more expensive cartridge being used. That's definitely NOT true. Pretty much all the regular opiate assays will pick up oxy at a certain concentration threshold (one that can realistically be seen in people in real life).

For example, our regular old basic opiate assay (single reagent, no upgrades/add-ons) from our toxicology lab targeted at morphine metabolites picks up Oxy no problem at levels you can reasonably expect to see in people (although you definitely wouldn't want to use it to screen specifically for oxy). However, in our core lab, the analyzer will give a negative for those same samples. We did a 48 patient sample comparison between the two labs and 13 samples gave discordant neg/pos results between the two labs. Tox lab's GC/MS confirmatory testing was done to find out the cross-reactivities responsible for the discrepancies. 5 of the discrepancies were due to oxy, the others were due to hydrocodone and hydromorphone. This wasn't unexpected.

Hence why I just wanted to point out to everyone that these assays all behave very differently from each other and care is needed when making conclusions about results from them.

The moral being that if someone is used to never seeing oxy trip a postive on an opiate screen then goes to moonlight at a place with an analyzer like our tox lab where it will test positive often, they might mistakenly determine that a patient on oxy who trips a positive must also be on something additional and they could be wrong.

So the laboratory operations management team I'm on got to spend quite a bit of time with the 10 or so laboratory directors for our health system sites having discussions how we were going to make providers aware of these differences when we shifted the ED drug screen from the tox lab to the core lab. Then more discussions with the ED folks on whether or not the performance of the assay was going to meet their needs.

 

[Birdstrike]

OTC Vicks nasal spray can give a false positive for Meth, by the way, on dipstick and even on a GC/MS confirmation.

And poppy seeds really can give a false positive morphine. It well documented

Just sayin'

 

[Birdstrike]

Nitpicky

Agree