Urine Tox. Screens

[HeyDoc]

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I'm curious if anybody knows what pharmaceutical opioids DO NOT show up on a standard Urine toxicology screen. There is some debate brewing amongst colleagues and in looking at the package inserts it doesn't give much insight.

Thanks for the help and references would be nice

 

[PMR 4 MSK]

Are you talking about dispsticks done in the office, or samples sent out for GC/MS?

 

[lobelsteve]

I'm curious if anybody knows what pharmaceutical opioids DO NOT show up on a standard Urine toxicology screen. There is some debate brewing amongst colleagues and in looking at the package inserts it doesn't give much insight.

Thanks for the help and references would be nice

Or just a patient looking how to scam a screen....

SAMHSA screen for the big 5: opioids will pick up Heroin, Morphine, and Codeine. Nothing else.

There are dozens of dipstick tests available and it is impossible without knowing the manufacturer what technology (assay) they are using and what cutoffs are being looked at.

I do not make clinical decisions based on dipstick or EMIT testing. GC/MS is very difficult to fake out- and I won't post how to do so here.

 

[Mister Mxyzptlk]

The conventional dipstick tests are really just morphine and they pick up codeine and heroin because of their metabolism to morphine. You can buy cups with methadone and oxycodone now. I am not too happy with the oxy - it has generated a few false-positives.

Sometimes I wonder if we should bother with the in-office screens at all because there are so many false-positives and false-negatives. Even GCMS can be hard to interpret because of all the cross-metabolites, like hydrocodone to hydromorphone, etc.

 

[Tenesma]

cross-metabolites are the biggest issue

and there will always be that group of patients that is just too smart and too good for us to ever detect - until they get greedy or too confident and trip up...

 

[lobelsteve]

The conventional dipstick tests are really just morphine and they pick up codeine and heroin because of their metabolism to morphine. You can buy cups with methadone and oxycodone now. I am not too happy with the oxy - it has generated a few false-positives.

Sometimes I wonder if we should bother with the in-office screens at all because there are so many false-positives and false-negatives. Even GCMS can be hard to interpret because of all the cross-metabolites, like hydrocodone to hydromorphone, etc.

I do not do any dispstick or EMIT testing. All urine is sent out for GC/MS. Almost no FP/FN rates. Detects all adulterants.

Practice decision is to give 1 week of meds while awaiting results or give 1 month of meds and if problems found on testing get them to addictionology, law enforcement prior to next visit.

 

[Ligament]

I do not do any dispstick or EMIT testing. All urine is sent out for GC/MS. Almost no FP/FN rates. Detects all adulterants.

Practice decision is to give 1 week of meds while awaiting results or give 1 month of meds and if problems found on testing get them to addictionology, law enforcement prior to next visit.

steve, which company are you using for GC/MS and how do you get the added expense covered? I've been talking with Ameritox lately but have not tried them yet. Their charge to insurance is very high.

 

[lobelsteve]

I am aware of three vendors, but there are certainly a few others.

Ameritox, AIT, Calloway

The cost is not an issue with me. I do not bill, I do not collect, I do not know, I do not care.

OK, so I care a little. But it will not affect my screening in any way, shape, or form.

UDS is an essential part of caring for patients on opioids. When the DEA and FDA decide to make all opioids OTC, I will stop testing.

If I was an asshat like many of the docs I have encountered in practice, with no testing, no informed consent, no limits, then the government will intervene restricting access further to the patients who may need these "essential" medications. 1986 WHO expert committee recommendations for opioid analgesics as essential drugs: “those that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in the appropriate dosage forms”

So while 25% of my patients are misusing their medications and 5-10% may be diverting on some scale; I can only catch 10% of the 5-10% of the diverters based on my clinical acumen. I let the pee sort it all out. My rules are strict and the law is clear. Diversion must be reported to law enforcement. The DEA knows everything you are doing but lacks the manpower to come after you. Fly straight.

 

[spinepain]

Do you report to the DEA? Or local law enforcement?

Do you make a phone report or a written report?

I haven't done this but think maybe I should start.

 

[lobelsteve]

Do you report to the DEA? Or local law enforcement?

Do you make a phone report or a written report?

I haven't done this but think maybe I should start.

The Federal law states a requirement to report suspected diversion. it soes not say to who or how. I am unaware of anyone prosecuted for not doing so unless they were also guilty of misprescribing or aiding and abetting.

You can notify your local police or state agencies. The DEA is understaffed, but if your local/state law enforcement follows up on your report, the scope of the ex-patient's misbehavior may reach the DEA.

In Georgia we have a Department of Narcotics and Alcohol. I have staff call their office and then send a fax. That satisfies the requirements under the law.

 

[Mister Mxyzptlk]

Ameritox is expensive. I switched to AIT.

I doubt many people actually report every instance of drug abuse to the police. I also doubt the police would be interested unless there is more to the story than a positive urine test. They don't chase after the users much. They focus on the supply chain.

The DEA doesn't know "everything" you're doing. To a certain extent they use database screens to look for prescribing patterns, and if yours is interesting they take a look. If you prescribe a lot of opioids you have probably been looked at (and survived the scrutiny). I don't know what patterns they look for. They won't tell me.

If you are coloring inside the lines they will not be interested in you. The Iraq war and Homeland Security have gutted LE budgets. They have to spend their resources where it will make the biggest impact so they have to focus on the real outliers. These are very hard cases to prosecute and very expensive. Doctors aren't usually being defended by Legal Aid and Public Defenders and cutting easy deals. It's very hard to prove that the drugs were not being prescribed outside the course of usual care. The Portenoys of the world will line up to defend you. Look at how well Hurwitz was able to defend himself.

Therefore LE mostly pursues egregious cases that are clearly drug dealing. A guy whose office consists of a card table and a prescription pad is extremely interesting, as is a doctor who prescribes drugs to a patient in exchange for some of the pills. A pain doctor who is practicing legitimately but got conned for some Vicodin scripts doesn't interest them.

You will incur LE problems (DEA or local) if they notice a lot of miscreants being arrested, driving into roadside objects, or OD'ing with pill bottles with your name on them in their possession.

When the patients complain about the UDT I tell them "I just need something to show the judge".

 

[drusso]

UDS is an essential part of caring for patients on opioids. When the DEA and FDA decide to make all opioids OTC, I will stop testing.

--SNIP--

So while 25% of my patients are misusing their medications and 5-10% may be diverting on some scale; I can only catch 10% of the 5-10% of the diverters based on my clinical acumen. I let the pee sort it all out. My rules are strict and the law is clear. Diversion must be reported to law enforcement. The DEA knows everything you are doing but lacks the manpower to come after you. Fly straight.

I agree. As long as Rx'ing opioids is a liability risk, UDS is the only tool I really have to manage that risk.

 

[Mister Mxyzptlk]

I asked my office if we should get rid of the dipsticks in the office and they asked me who would treat the patients if I left. I don't get no respect.



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