Uds

[Jeff05]

i will be starting pain fellowship next year and had a couple of questions regarding use of the UDS.

if a patient knows that they have an upcoming office appointment during which their urine will be screened - why don't they just stop what they're not supposed to be doing and start what they're supposed to be doing, accordingly.

so for example,

1. if they took two doses of percocet (oxycodone) - not chronic, how long would their uds remain positive (assume screening 100ng/ml)? i realize the half life is about 5 hours, but what is the actual clinical correlate? ie how many days?

2. same question with oxycontin

3. same with amphetamines

4. same with xanax and valium

5. soma

thanks,
jeff

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[dc2md]

Jeff,
First, the urine drug screens are supposed to be random for that exact reason.

I can only comment on the opioids question. Had a patient last week that said she took her last perc on sat and it was Monday. So we looked up how long the narcotic would still test positive in urine, and the guide from the UDS company said 2 days. Since she was pretty much two days off, that seemed pretty much right on the borderline so we didn't test (could've rationalized either result).

 

[PMR 4 MSK]

UDS is tricky and only a tool. There are a lot of potentially false negatives and positives.

Most meds of abuse are in the system 2-5 days.

In my book, if you are having to worry about someone taking Oxycontin, Soma and Xanax, you're on the wrong side on pain management.

 

[Aether2000]

Pain physicians should be experts in medication management and the resource to which other doctors turn for advice and to comprehensively manage patients. The days of the one trick pony needle jockies are limited and only physicians with a full armament of techniques, knowledge, and skills will survive. Therefore the question re: UDS is valid, but also very complex. There are several different types of UDS using differering technologies and with differing cutoffs. One must pick a UDS specifically designed for the drugs of interest and not the generalized "opiates" or "morphine" which are frequently falsely negative for the semisynthetics and all the synthetics. It is also important to note all the drugs being taken, including OTCs and nutritional supplements, drugs from dentists, etc as some of these will interfere or cause false positives or negatives. The physician should never act on the UDS alone without giving the patient the option to pay for a confirmatory test (GC/MS or LC/MS) or obtain the confirmatory test themselves. Too often patients are discharged from pain practices because the physicians erroneously rely on the UDS dipstick method as a sole means of determination. The times of detection from the last dose varies depending on the preset detection level cutoffs.
Finally, the UDS (random, targeted during appointment, targeted inbetween appointments) is but one method that should be employed for the detection of illicit substances, the proof the patient is taking the medication especially if the medication is a non-prn scheduled medicine, and that the patient is not obtaining other opiates surreptitiously. The state prescription drug tracking programs should be used on all new patients (we query these prior to even accepting the patient into our practice) and randomly thereafter. Mandatory pill counts mid month are employed if we suspect drug diversion or have reports the patient is selling the drugs.
The UDS is only useful if the physician AND patient understand how it will be used, the options for confirmation and limitations of the test, and the consequences spelled out in writing in advance in an opiate prescribing agreement (but that is another subject).
Opiates generally are detectable up to 72 hours in a UDS and longer in GC/MS, LC/MS with low cutoff values. You can ask the confirmatory lab for actual values rather than a positive or negative, and some will automatically provide these. Marijuana may be detected up to 30 days after use. Other detection times: PCP: 14-30 days, Amphetamines: 24-72 hrs, Cocaine: 24-96 hrs, Benzodiazepines: days to many weeks

 

[foxtrot]

Pain physicians should be experts in medication management and the resource to which other doctors turn for advice and to comprehensively manage patients. The days of the one trick pony needle jockies are limited and only physicians with a full armament of techniques, knowledge, and skills will survive. Therefore the question re: UDS is valid, but also very complex. There are several different types of UDS using differering technologies and with differing cutoffs. One must pick a UDS specifically designed for the drugs of interest and not the generalized "opiates" or "morphine" which are frequently falsely negative for the semisynthetics and all the synthetics. It is also important to note all the drugs being taken, including OTCs and nutritional supplements, drugs from dentists, etc as some of these will interfere or cause false positives or negatives. The physician should never act on the UDS alone without giving the patient the option to pay for a confirmatory test (GC/MS or LC/MS) or obtain the confirmatory test themselves. Too often patients are discharged from pain practices because the physicians erroneously rely on the UDS dipstick method as a sole means of determination. The times of detection from the last dose varies depending on the preset detection level cutoffs.
Finally, the UDS (random, targeted during appointment, targeted inbetween appointments) is but one method that should be employed for the detection of illicit substances, the proof the patient is taking the medication especially if the medication is a non-prn scheduled medicine, and that the patient is not obtaining other opiates surreptitiously. The state prescription drug tracking programs should be used on all new patients (we query these prior to even accepting the patient into our practice) and randomly thereafter. Mandatory pill counts mid month are employed if we suspect drug diversion or have reports the patient is selling the drugs.
The UDS is only useful if the physician AND patient understand how it will be used, the options for confirmation and limitations of the test, and the consequences spelled out in writing in advance in an opiate prescribing agreement (but that is another subject).
Opiates generally are detectable up to 72 hours in a UDS and longer in GC/MS, LC/MS with low cutoff values. You can ask the confirmatory lab for actual values rather than a positive or negative, and some will automatically provide these. Marijuana may be detected up to 30 days after use. Other detection times: PCP: 14-30 days, Amphetamines: 24-72 hrs, Cocaine: 24-96 hrs, Benzodiazepines: days to many weeks

This is a really good response to a very complicated subject. I find that narcotic contracts are not as simple as they seem. In fact, my fellowship doesn't even use them. We do random UDS and pill counts and mostly importantly we talk to the patients and avoid prescribing benzo's and things like soma. I would be interested to hear some examples of the way others have gone about constructing an opiod contract (for those of you who use them). How do you work them in regard to positive UDS's? This is a very interesting topic.

 

[axm397]

we don't have a contract - just an agreement. no pain/benzo Rx from any other provider (we will run CURES forms on them randomly or if we suspect), no early refills, no replacement for lost or stolen (will detox them if needed), no self escalation of doses need to call us, no illegal drugs including marijuana (federal institution), no mixing with alcohol.

if violate above, offer non-opioid pain management only. will do rapid taper. sometimes use tramadol. addiction consult as appropriate.

 

[Jcm800]

In my book, if you are having to worry about someone taking Oxycontin, Soma and Xanax, you're on the wrong side on pain management.[/QUOTE]


well said!

 

[powermd]

We take a fairly non-confrontational role at UC Davis. We do very little direct prescribing of opioids, which makes it a lot easier since the scripts are not coming from our own pads. We get UDS/CURES reports on almost every new patient on opioids who is referred for medication management. We send out inappropriately negative GCMS samples to a lab in Utah for ultra-low threshold testing. We tend not to confront patients with the information until we have time to collect another sample to see if the results are consistent. There are a lot of reasons why your initial results may be wrong, and we assume that the truly aberrant patients will ultimately declare themselves one way or another. I may feel different about this approach when it's my license on the line, but as along as you have a consistently applied strategy in place to manage the risk of prescribing opioids, you should stay out of serious trouble.

One thing that I've learned from the elders at my institution is that we're not opioid police. Minimize the risk to your patient, and to society, and you've done your job. The risk to society of one more addict or diverter getting a refill of his Oxycontin is small, but the risk to a patient in pain with genuine need from being fired over one lab test is tremendous. It's probably better to be fooled by 100 fakers than miss one patient with a genuine need. That thought helps me maintain empathy for patients I otherwise would dismiss.

 

[Faebinder]

We take a fairly non-confrontational role at UC Davis. We do very little direct prescribing of opioids, which makes it a lot easier since the scripts are not coming from our own pads. We get UDS/CURES reports on almost every new patient on opioids who is referred for medication management. We send out inappropriately negative GCMS samples to a lab in Utah for ultra-low threshold testing. We tend not to confront patients with the information until we have time to collect another sample to see if the results are consistent. There are a lot of reasons why your initial results may be wrong, and we assume that the truly aberrant patients will ultimately declare themselves one way or another. I may feel different about this approach when it's my license on the line, but as along as you have a consistently applied strategy in place to manage the risk of prescribing opioids, you should stay out of serious trouble.

One thing that I've learned from the elders at my institution is that we're not opioid police. Minimize the risk to your patient, and to society, and you've done your job. The risk to society of one more addict or diverter getting a refill of his Oxycontin is small, but the risk to a patient in pain with genuine need from being fired over one lab test is tremendous. It's probably better to be fooled by 100 fakers than miss one patient with a genuine need. That thought helps me maintain empathy for patients I otherwise would dismiss.

Indeed, the psychiatry wards half full of addicts rather than psychotics, manics or depressed patients are very thankful as well. And yes I think you will change your mind after you get your license, I'm surprised the fellowship doesn't require it.

 

[axm397]

The risk to society of one more addict or diverter getting a refill of his Oxycontin is small, but the risk to a patient in pain with genuine need from being fired over one lab test is tremendous. It's probably better to be fooled by 100 fakers than miss one patient with a genuine need. That thought helps me maintain empathy for patients I otherwise would dismiss.

We always give the patient the benefit of the doubt that they might truly have pain. But we also tell them that not all pain has to be managed with opiates and if they violate the terms, we can offer them non-opiate pain management. If they truly have pain, they will continue to come to our clinic, and after 3-4 appropriate negative urine screens and CURES form, we will re-institute the opiate therapy if they still have pain after the few months of trying non-opiate pain management. We have had some patients get better with PT, HEP, modalities, tramadol, bahavioral therapy, and adjuvants and not need to go back on opiates. The other patients, we can start at a much lower dose of opiates.

Our clinic is a consult clinic as well but we continue to see the patients until they are "stabilized" on a dose and have had several appropriate urine screens and have not shown any behavior of concern before we "discharge" them back to their PCPs to write their chronic opiate scripts. We'll bring the patients back every month - and sometimes every week or 2 weeks - until we get the right regimen for them. We rarely do monotherapy with only opiates. We also have psychology see every new patient - we often miss a lot of interesting information that these psychologists tend to get.

 

[foxtrot]

What is a CURES report? We don't use these?

 

[PMR 4 MSK]

We are the opioid police. No one else will be, except to sue or prosecute you. Document everthing, it will all be used for you and against you. Society expects you to be able to tell an addict from a pain pt, an abuser from a user. violations of an opioid agreement needs to be fair and consistent, allow for extenuating circumstances, and assume every excuse is probably BS but you probably can't prove it.

If you prescribe opioids, you will have abusers, and every one of them will push you as far as you will let them. Learn to identify behaviors, mannerisms and characteristics suggestive of abuse. Trust but verify. Accept you will get burned and learn from it. Get family members involved and on your side.

Know that a pain pt and an addict will preset to you identicle to one another, and usually only time will sort them out. Know that you will sometimes be wrong, and make sure everything is well documented before it does.

 

[axm397]

What is a CURES report? We don't use these?

It's california specific
CURES = Controlled Substance Utilization Review and Evaluation System
http://www.ag.ca.gov/bne/trips.php

 

[Tenesma]

PMR --- agreed that MOST pain patients and addicts will present in a similar fashion --- the addicts will have your bells ringing and your flags waving within the first 48 hours...

 

[Aether2000]

Banner week thanks to UDS with confirmation/monitoring: within the past week, 3 positive for THC, 1 positive for methamphetamine, 3 positive for opiates we are not prescribing, 2 refused pill counts in mid month, all had opiates discontinued by us. UDS works.

 

[PMR 4 MSK]

Banner week thanks to UDS with confirmation/monitoring: within the past week, 3 positive for THC, 1 positive for methamphetamine, 3 positive for opiates we are not prescribing, 2 refused pill counts in mid month, all had opiates discontinued by us. UDS works.

Outta how many tested, out of curiosity? Also curious, is this truely random testing, or do you just test the suspicious ones?

 

[Jeff05]

so if patient is positive for THC - you dismiss them from your practice?

 

[Tenesma]

i think it is wrong to adopt the mentality of dismissing a patient from a practice due to a positive UDS.... easier (and legally less thorny) process of just telling the patient you want to keep them in your practice, but you no longer believe chronic opioid therapy is indicated in their care, that you will wean them off opioids and that you will focus on non-opioid approaches --- and if they say they have already tried everything and nothing works, then just smile and say "i am going to refer you for Reiki evaluation"

THC is illegal according to the DEA --- and we have our controlled substance privileges through the DEA... so a THC is just as bad as a Cocaine or as a non-prescribed benzo...

 

[drvlad2004]

so if patient is positive for THC - you dismiss them from your practice?

Usually yes since it was stated on the pain contract. Rarely, I will give that patient a second chance with THC. If they have a history and good compliance, go the psych and addictionology, then maybe they get a second chance. There may be false positives if a patient is taking phenergan. Confirmatory UDS, GC/MS, will further determine if the patient is truly taking marijuana.

With UDS, I also look very carefully at the quantitative results. If there is an abnormally high or low amount of a specific opiate, then I have to interrogate that patient. This is specifically out of concern of possibly stockpiling meds, diversion, or not taking meds the way that they were prescribed. Also with opiates, I look carefully at the long acting opiates compared to the prn meds. The prn meds may be taken infrquently because of good pain relief from long actings. I don't prescribe more than TID for prn meds since those more frequently abused. Also with UDS, I always ask when the last time the patient has taken their meds (short acting, long acting, benzos, etc) prior to ordering UDS so that I can have that documented. Oftentimes, a patient will attempt to give a BS excuse or state that they told you on previous visit that they were sick and did not take any meds for days after the results come back.

I also make track and monitor a patient's Rx history through INSPECT, which is in Indiana. Other states have a similar system.

 

[Tenesma]

drvlad2004 - what the???

 

[clubdeac]

So with quantitative testing . . . first, is that the same as GC/MS? And second, do serum levels really correlate well with the amount of opioid ones taking? I've heard it doesn't. And if not, is there any way of telling whether someone's taking all of their medication or just half of it and diverting the rest??? Any thoughts

 

[Aether2000]

Serum levels correlate neither to pain relief or urine drug concentrations. There are some companies that will give an "expected drug level" based on specific gravity x concentration of a drug and have normal values but these levels have not been verified in the chronic pain population, nor take into account the 8 fold variation in drug levels needed to achieve analgesia. Therefore, it is not possible to determine whether a person is diverting part of the drug based on UDS or serum levels.
Diversion and substance abuse are more aptly determined using a mid-prescription cycle mandatory pill count.

 

[clubdeac]

Thanks algosdoc! That helps

 

[PMR 4 MSK]

Diversion and substance abuse are more aptly determined using a mid-prescription cycle mandatory pill count.

The only way I know how to do that is to have someone call the pt and tell to come to the office today, right now and bring your pills. 50% don't answer the phone or let everything go to voice mail and 49.99% will have an excuse why they cannot come immediately or today - car broke down, no ride, gotta work, not at home, gotta take my dog to the vet, etc.

Otherwise, if you tell them to come in next Tuesday, or even tomorrow, they have plenty of time to borrow the drugs from someone else or get another Rx from their PCP, an urgent care center, ER or the pain guy down the street.

 

[Mister Mxyzptlk]

Sometimes I think we should be testing the spouses too. More than once when I've refused a refill an angry spouse called the office and yelled at the staff. More often than not, they sounded intoxicated.

 

[clubdeac]

Help..... I've got a patient taking Norco 10s, 5x/day and has been so for some time. I was trained that standard immunoassay UDS are often (-) for opiates in patients on less than 100mg oxycodone/day but I thought most immunoassays pick up all doses of hydrocodone. Is this everyone else's understanding???? The reason is, my guy on hydrocodone had a (-) UDS for opiates. If my understanding is correct, the guy's selling and not taking his happy pills.... Any thoughts???

 

[Aether2000]

Could be selling, could have taken a higher dose at some point in the last month and run out of meds early, could have lost or had the meds stolen, or he could be taking them but the immunoassay is not sensitive enough to pick up the meds. Steps that need to be taken: 1. check the refill history (state monitoring report if available, or pharmacy report where he is filling the medication) 2. obtain a GC/MS or LC/MS confirmatory analysis on the same specimen 3. write a script for only 3-7 days worth of medication while awaiting the UDS confirmation then have the patient scheduled to come back and see you 4. change your prn scripting for opioids to write "max 5/day" on the prescription and there will be no way to run out early without exceeding the prescribed amount

 

[hyperalgesia]

If this patient needs opiates 5x/day, I would convert to primarily long acting meds. Maybe a BID dosing of IR for breakthrough with the understanding that this will also eventually be converted to long acting. I think the UDS is particularly inaccurate for short acting meds. After conversion to LA meds, if the UDS continues to be negative, with specific drug testing, and with the patient continuing to claim he is compliant, we consider that a breach of contract. Maybe that is harsh but it's the way we do it. Five of our patients were recently arrested for diversion, getting meds from multiple pharmacies, etc.

 

[clubdeac]

Thanks for the advice. He recently came to me on norco 10 5x/day. It was definitely not my regimen. I will probably have to go GC/MS. Just wanted to get an idea if monoclonal immunoassays are sensitive enough to pick up hydrocodone which I thought they generally were. Thanks for the help though. And algosdoc, I just checked out your website and went through a few of those pp presentations. That's some great stuff. Thanks a lot!

 

[painrelief]

Besides understanding the basics of opioid metabolism, does anyone know any good source to look up what non-opioid meds can cause false positives for opioids/amphetamines/THC?

I have used Ameritox GC/MS on several occasions, and for inconsistent findings, they wisely write "this could be due to individual metabolism...."

Having said that, it is even more challenging to distinguish between patient's who are telling the truth vs. patients diverting meds.

I realize the UDS is just a tool, but I'm just interested in getting the most out of its use. I also would like to be better prepared if non-pain docs ask me about these details...

 

[lobelsteve]

Besides understanding the basics of opioid metabolism, does anyone know any good source to look up what non-opioid meds can cause false positives for opioids/amphetamines/THC?

I have used Ameritox GC/MS on several occasions, and for inconsistent findings, they wisely write "this could be due to individual metabolism...."

Having said that, it is even more challenging to distinguish between patient's who are telling the truth vs. patients diverting meds.

I realize the UDS is just a tool, but I'm just interested in getting the most out of its use. I also would like to be better prepared if non-pain docs ask me about these details...

Using LC/MS techniques, adulterants are identified and no false positives from other meds. Relying on a dipstick for clinical decisions is fraught with error. Always err on the side of logic. If it walks like a duck, quacks like a duck, and asks for Vicosomaxanax, it's a F'd up duck.

 

[stim4u]

sometimes I have problems with patients returning with positive marijuana results. When I see it in an elderly patient with significant pathology, I tend to let it go, with a reprimand. In the mid-aged to young, they are addressed quite harshly. I have had urine tox screens positive in some patients who are adamant they did not use it, and a UDS within a day were negative. To add to this conundrum, my state allows a certain amount (1g?) without criminal prosecution. So I usually take each marijuana case by case and retest. Are others having issues with marijuana positive UDS?

 

[lobelsteve]

sometimes I have problems with patients returning with positive marijuana results. When I see it in an elderly patient with significant pathology, I tend to let it go, with a reprimand. In the mid-aged to young, they are addressed quite harshly. I have had urine tox screens positive in some patients who are adamant they did not use it, and a UDS within a day were negative. To add to this conundrum, my state allows a certain amount (1g?) without criminal prosecution. So I usually take each marijuana case by case and retest. Are others having issues with marijuana positive UDS?

It is a federal offense under jurisdiction of the DEA, same guys who hold our prescribing authority. 1st test + means they will be retested within 45 days and has to be negative or greatly reduced ng/dl. If 2nd test + then all controlled Rx's are DC'd. Consider for addiction consult, continue to treat with non-narcotics.

Half my patients stop or smoke infrequently enough that the repeat UDS are negative consistently, and the other half decide THC is better than my care provided.

 

[hyperalgesia]

I just saw a guy for the first time asking for Nucyntasomanax. His primary care notes (on EMR) say he's been testing pos for cocaine on a monthly basis for the past year. The MD who screened the consult was apparently sleeping. Surprisingly, he declined my offer of acupuncture, interventions and a SA consult. Isn't cocaine against the law? Sometimes I wish we could just call the police. F#ck.

 

[painrelief]

i got a guy apparently on oxycodone ER TID and IR prn. Recent GC/MS shows hydromorphone, and NO oxycodone, noroxycodone or oxymorphone......

obviously the red flags have gone up, and the UDS is an extension of the whole clinical picture.... but some of the drug screening handouts mention that hydrocodone can be a commercially manufactured impurity.... thus is it possible the hydromorphone is coming us as a metabolite of the impurity issues.

I know that if it walks like a dog and acts like a dog, then its a freaking dog.... but i just wanted your thoughts on this type of issue.

 

[lobelsteve]

I just saw a guy for the first time asking for Nucyntasomanax. His primary care notes (on EMR) say ha's been testing pos for cocaine on a monthly basis for the past year. The MD who screened the consult was apparently sleeping. Surprisingly, he declined my offer of acupuncture, interventions and a SA consult. Isn't cocaine against the law? Sometimes I wish we could just call the police. F#ck.

Your DEA registration REQUIRES you to notify law enforcement if you suspect diversion. If opiate patient with + cocaine or meth- you should notify your state or local narcotics squad. Your registration could be at risk.

 

[clubdeac]

i got a guy apparently on oxycodone ER TID and IR prn. Recent GC/MS shows hydromorphone, and NO oxycodone, noroxycodone or oxymorphone......

obviously the red flags have gone up, and the UDS is an extension of the whole clinical picture.... but some of the drug screening handouts mention that hydrocodone can be a commercially manufactured impurity.... thus is it possible the hydromorphone is coming us as a metabolite of the impurity issues.

I know that if it walks like a dog and acts like a dog, then its a freaking dog.... but i just wanted your thoughts on this type of issue.

High doses of hydrocodone should/can produce some hydromorphone in the GC/MS just like high doses of oxycodone can/should produce oxymorphone. But oxycodone does not produce metabolites that could be confused with hydromorphone. And very high doses of morphine can even produce hydromorphone on the GC/MS

 

[drf]

sometimes I have problems with patients returning with positive marijuana results. When I see it in an elderly patient with significant pathology, I tend to let it go, with a reprimand. In the mid-aged to young, they are addressed quite harshly. I have had urine tox screens positive in some patients who are adamant they did not use it, and a UDS within a day were negative. To add to this conundrum, my state allows a certain amount (1g?) without criminal prosecution. So I usually take each marijuana case by case and retest. Are others having issues with marijuana positive UDS?

My personal preference has been no schedule 2 with + marijuana, mostly as a reason to not Rx these things for beign pain anyways. However, CA recently made possession an infraction. Not felony. Not misdemeanor. An infraction. This is like a parking ticket. With MJ that available it seems that I should be more lenient.

 

[Axehandler]

The initial poster's question has som nuance that no one has addressed. When people test positive for illicits or non-prescribed drugs even though they know they will be tested they are addicts. They continue to use despite self harm-they are choosing to put their relationship with you at risk. This is much more informative than a random screen that might catch a recreational/occasional user. Someone who can't forego use for 2 days before seeing you needs an addiction consultation and treatment. I discontinue opiates and re-instate and closely monitor when psych says their pain is the problem, not addiction. Pill counts are worthless-way too easy to rent/borrow someone else's.

 

[MedZeppelin]

For anyone doing in-house UDS and Billing for it, could you recommend a supplier for UDS cups (panel #) and which CPT codes to bill for?
Also, I hear that the reimbursements are changing with Medicare???

 

[Aether2000]

Pill counts are not easy to get around if the patient is told to go back to their pharmacy within 12 hours for the pill count. To obtain exactly the medication that was dispensed by the pharmacy, especially when a generic is used, may be difficult within 12 hours. We have lost many patients to those who refused pill counts.
One should be very very careful about reinstituting opioids in a person with a history of substance abuse within the past few years. The recurrent abuse rate is very high, well over 50%. There were an estimated 15,000 people in the US who died last year (CDC) from prescription opioid medications- more than all other illicits combined. In front of a medical board or a judge, you would fry if you had a patient who overdosed and died after you had previously stopped prescribing for substance abuse, then re-initiated such therapy later.

 

[painstop]

Have any of you guys performed in-office pill swallows followed by drug screens for people who insist they are taking their medication and come up negative? I figure if they are willing to pay for it and a positive result is grounds for no further opiate prescribing since they "magically" started having it show up in their system, it seems reasonable. I know you have to watch the patient for a set period of time to make sure they don't go to the restroom and vomit out the pills to prove their point. How long do you have to watch them before you can get a valid urine drug screen and send the patient on their way?

 

[PMR 4 MSK]

Have any of you guys performed in-office pill swallows followed by drug screens for people who insist they are taking their medication and come up negative? I figure if they are willing to pay for it and a positive result is grounds for no further opiate prescribing since they "magically" started having it show up in their system, it seems reasonable. I know you have to watch the patient for a set period of time to make sure they don't go to the restroom and vomit out the pills to prove their point. How long do you have to watch them before you can get a valid urine drug screen and send the patient on their way?

Way too much work, too many pitfalls as you suggest, and serves as an example that at the point, the entire patient-physician relationship is undermined. If it gets to that point, it is too late.

 

[clubdeac]

doc ***** here with a question. Patient is on xanax. Got a UDS and came back positive for alprazolam but negative for its metabolite alpha-hydroxyalprazolam. I assume this means the patient dropped a tab of his pills into the urine and actually isn't taking the med? Is this correct whenever a metabolite doesn't show up?? Algos thoughts

 

[Aether2000]

If the amounts detected are off the chart, then the patient dropped the pill into the urine. If they are reasonable amounts in the 100-2000 ng/ml range then the patient may have taken the drug within an hour of the appointment. Chronic daily use should detect the metabolite. If the metabolite is not present then the patient has probably not been taking the drug for days to weeks, meaning 1. they are selling part of the drug supply or giving it away 2. they are overusing the drug early on each month and are saving some for the day of the drug test or 3. they are using it only intermittently. Next step should be a pill count mid month.

 

[clubdeac]

Thank you Algos!

 

[Ducttape]

if i might also ask a question, to clubdeac. are you getting a quantitative report, an actual number, or just a qualitative +/- result? i get both, just wondering if you are.

 

[clubdeac]

if i might also ask a question, to clubdeac. are you getting a quantitative report, an actual number, or just a qualitative +/- result? i get both, just wondering if you are.

So I just started at this practice. I looked and it just gives me a positive or negative result. I agree, I would like a number. I'm going to go visit the lab next week to get more info.

 

[Aether2000]

If it is a hospital lab, most are incapable of quantitative toxicology studies...

 

[Ducttape]

cause most are doing immunoassays for the Emergency Department.

ive worked with my lab a lot, and they produce, i believe, a quality result. LC/GS, qualitate all drugs of misuse, quantitate all positives, quantitate specific drugs asked for and specific screens for oxycodone, buprenorphine, tapendatol, and tramadol including metabolites, as low as 20 ng/ml for opioids....

the key is spending the time working with them, pushing them to give it all...