Clinical Pearl of the Month – Urine Drug Testing

Gerard Kiernan, MD, FAAFP, FHMClinical Pearls, Medical News

Clinical Pearl of the Month

Today’s Clinical Pearl of the Month question comes from the desk of Med-Challenger Family Medicine Editor, Gerard Kiernan, MD, FAAFP, FHM.

Test your skills with this review question.

Review Question

A 48-year-old man presents as a new patient, transitioning from a colleague who is retiring. He had a motor vehicle crash ten years prior, and, since then, has suffered from chronic low back pain. He works as a carpenter, does not drink alcohol, and has no history of drug abuse.

Your colleague has been treating him with chronic opioids for the last five years, and he has been on stable doses of both long and short-acting oxycodone. The patient does not have a record of aberrant behavior, such as lost or stolen prescriptions, compulsive use, or reluctance to try non-pharmacologic therapies. He has, in the past, been evaluated in both a spine clinic and in a pain clinic, and interventional pain therapies were tried early in his treatment, with only temporary and limited efficacy.

You review his current and prior treatment with him, and you and he agree to revise his pain treatment agreement to include regular urine drug testing, after you explain the rationale.

At your visit, you obtain a urine specimen that is sent for urine drug screen. The result of the screen is negative for opioids.

Question

Which of the following is the appropriate next step, based on that result?

Answer Options:

Send urine for gas chromatography confirmatory testing for oxycodone.

Repeat drugs of abuse urine screen to confirm negative result.

Taper patient’s chronic opioid therapy based on negative result indicating likely diversion.

Ask patient to come in and discuss why urine sample is negative.

Answer Explanation & References:


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About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

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