Clinicians have few tools to monitor pain medication use and abuse in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.

A jar containing a urine sample copyright toeytoey2530/Thinkstock

“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.

Dr. Salsitz offered these tips about urine tests in pain care:

Consider urine tests before beginning opioid therapy

Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”

Ask the patient what the urine test will reveal

Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.

Begin with an immunoassay panel test (IA)

The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”

Understand what IA tests do and don’t do

Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.

Don’t make assumptions about positive or negative tests

A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.

Be aware that patients may fake urine tests

“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.

Dr. Salsitz reported no disclosures.

The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.