You do not know what you are doing. LCMS confirmation has no false positives or negatives. Dipstick testing is useless. If the results from the lab are negative, the specimen was not of that patient or the patient did not take opiates within 3 days of providing the sample.
Now if you choose to disregard the test and continue prescribing and an adverse outcome arises: death by OD, he crashes into a few school kids at the bus-stop.....you need to lose your license, face civil and possibly criminal charges.
Knew or should have known better. Listen to 101N on opiates. The meds are for a select few for chronic pain and not the majority of folks that ask, demand, or are already on them.
Risk denying treatment of his pain? Tylenol treats pain. Opiates are merely an option and you are being played.
Zofran and Zanaflex are 4mg tid for a week. #21 of each.
I'm calling BS on this. Nothing, is 100% accurate. No matter what the GC/MS lab rep tells you. No test, no X-ray, no MRI, nothing.
The simplest way to get a lab error on a GC/MS or LC/MS lab test is clerical error, ie, the lab tech enters the info on the report wrong, or puts the wrong result under the wrong name. 99.9% accurate is not 100% accurate. That being said you can't allow yourself to be manipulated because a test has a 0.1% error rate.
Also, I'm not going to tell anyone on the Internet how to treat a patient I've never examined or spoken to myself, no matter how clear cut it seems. Speak in generalities? Yes. Tell another doctor what to do or prescribe for a specific patient over the Internet? No.
That being said, I agree that in office UDS dipsticks are very inaccurate, and there is a huge rate of false + and -. Also, it's an error problem inherent in the poor technology of dipstick testing. GC/MS and LC/MS are several orders of magnitude better. But you can never take out the element of human error.
Also, the incredibly high sensitivity can give at some point lead to errors. For example, the test is so damn sensitive that there's been reports of positives from a pill count on a surface where previously different meds were counted and it picks up both meds on the sample. Or, the patient keeps their pills in an old pill box that for a long time had pills of a different type in it, and the test is so sensitive it's picking up low levels from that previous pills. Admittedly, this will
not happen 99.9% of the time, and 99.9% of the patients who fail a UDS will claim it did. Don't be stupid. I'm as aware as anyone else that some patients will lie 1,000 times over to get opiates at times and these types of errors are very, very, uncommon.
Also, the history of the patient matters. A patient you know well, that has always been perfectly reliable with no aberrancy is a different animal than one that is very new and unknown to you. An 89 yr old lady, who took a leftover, legitimately prescribe Tylenol with codeine instead of her normal two percocets per day because she couldn't get in to see you the week before you went out of town, with a T#3 prescription showing on her PMP report from 8 months ago, is much different than 30 year old male who walks in to your office for the first time and has cocaine and marijuana on his UDS. The codeine taken by the little old lady can break down into multiple opiates in the UDS. Do you discharge her over this and send her to detox? Or repeat the sample, repeat the prescribing agreement discussion and rules and continue close monitoring?
In regards to the hypothetical new patient with cocaine and MJ in the urine, would I entertain any "false positive" of "the lab mislabeled my urine" excuses? No way.
Clinical judgement and context are everything. Be aware that medication abuse and diversion unfortunately, are much more common than lab errors. Have a high index of suspicion ALWAYS about abuse and diversion, and always address it with the best interest of the patient and your license in mind. If you make a reasonable decision based on the clinical scenario and document your reasoning, you should be fine. If you ignore an inconsistency, make an unreasonable decision or don't document your reasoning, then you invite trouble from lawyers, medical boards and other people whose jobs are to punish people.
