UDM Solutions

How Frequently Should I Test My Patients?

As the president of a clinical laboratory, I cannot answer this question for you. There are no published guidelines for urine drug testing frequency from any society, academy or association that I am aware of. As a physician, I can tell you about my experiences, the experiences of my colleagues and published research and recommendations.

I practiced pain medicine in a pain & addiction clinic, so most of my chronic pain patients suffered from the disease of addiction. So as not to appear as being biased (which we were often accused of), we tested every patient at every visit. Our three-strikes-and-you’re-out policy seemed to work well to keep motivated patients in the program, and refer others to a higher level of care. This policy of frequent testing allowed us to address relapse issues early, helped to build trust, and confirmed adherence. All of this improved the care that we delivered to our patients. What I learned through this process is to always give my patients the benefit of the doubt, as long as there’s a UDT collected to corroborate the history.

A colleague of mine uses a popular protocol for testing that stratifies patients based upon risk of misuse or addiction. Patients are placed into low, medium or high risk categories and tested accordingly (i.e., low risk - annually, medium risk - quarterly, high risk - every visit or 1-2 months). This strategy allows for early identification of patients who may be at risk of misuse or addiction and limits potentially unnecessary testing for low risk patients who are making progress in treatment.

Recommendations from research articles and pain medicine publications vary widely in specifics. Of those that recommend testing, some suggest testing every patient at every visit¹, while others suggest testing as a response to aberrant behavior.² There is research that indicates urine drug testing in combination with other clinical observations provide more insight into pharmacotherapy than either used separately.³

Until progress is made in guidelines for monitoring pharmacotherapy, it is up to each clinician to determine an appropriate testing protocol for their practice and their patients. I'd like to hear from you about how you determine testing frequency to monitor pharmacotherapy for your patients and what your experience has been (positive and negative). You can comment on this post or send me an email.

1. Katz NP, Managing Chronic Pain with Opioids in Primary Care. PainEDU.org Inflexxion Health Series, 2007.
2. Hammett-Stabler CA, Webster LR, A Clinical Guide to Urine Drug Testing: Augmenting Pain Management and Enhancing Patient Care. UMDMJ–Center for Continuing and Outreach Education, 2008.
3. Katz NP, et al., Behavioral Monitoring and Urine Toxicology Testing in Patients Receiving Long-Term Opioid Therapy. Anesth Analg 2003;97:1097-102.

Why Determining Drug Dose in Urine is a Myth

I have had several conversations where I have been asked if urine levels depict the dose and frequency of drugs detected in the urine. There is concern for both prescription medications (prescribed by that clinician or prescribed by other clinicians) and non-prescribed drugs. Clinicians need and want to determine a patient's adherence and extent of patient adherence. We also want to know if the medication, dose, and frequency prescribed is the best combination for our patient. We need to know how the patient is taking their medication so we can prescribe or adjust their medication accordingly. If a person takes too much or is not taking their medication, they can become ill either because of the medication or because the condition is not being treated appropriately. For these reasons and many more, it is understandable that clinicians are looking for a measurement that tells them specifically the drug dose and frequency that a patient is taking. Unfortunately, drug dose cannot be determined in a urine specimen. The only way you can know exact oral dosage and frequency is if you administer each dose to that patient.

Anne Nafziger, MD, MHS, PhD and Joe Bertino, Jr., PharmD, FCP, two clinicians who both have over 20 years of experience in drug development, clinical pharmacology, and clinical research and are also authors of the UDM: Opioids handbook, have published an exceptional article titled "Utility and Application of Urine Drug Testing in Chronic Pain Management With Opioids" in the January 2009 issue of the Clinical Journal of Pain. The article specifically describes the inability to determine oral drug dose in urine. One primary reason is genetic variations among people. A patient's genetic profile contributes to the rate and extent of ADME (absorption, distribution, metabolism, excretion). The genetic makeup of individuals is unique and therefore drug ADME is unique to that person. The article also states that in addition to differences between individuals, ADME may vary within a single person on a day to day basis. Due to these facts among others covered in the article, the authors state "...without blood concentration data, evaluating quantity of excreted parent drug in urine will not provide unequivocal evidence of patient ...(adherence) with recommended dosing."

So where do we go from here? Ultimately the goal is give our patients optimal pharmacotherapy. Currently, in the clinician-patient relationship, there is information we may collect and analyze to assist in assessing patient adherence. To move even closer to our goal, we need to utilize new tools and state-of-the-art technology. The motivation to write the UDM:Opioids handbook stemmed from the need for clinicians to obtain this information. Because UDM is a comprehensive monitoring strategy, it can provide more clinically relevant information than strictly knowing if the patient is taking the exact dose prescribed at the exact frequency prescribed. This will help shift the focus from drug dose to drug efficacy, and that is what will truly enhance our patients' treatment outcomes.

Welcome to the Companion Blog for the Urine Drug Monitoring: Opioids Handbook

Welcome to UDM Solutions, the companion blog for the Urine Drug Monitoring: Opioids handbook. Everyone involved in the creation of this handbook is excited about the launch of this new site and the important topics to be covered.

When we were planning the companion site, we thought a blog would be a great way to get readers involved in some of the new ideas presented in the handbook. UDM as defined in the handbook is a comprehensive strategy for monitoring pharmacotherapy. There are many ideas and techniques being integrated to form the complete strategy, and there are many ways to bring them together in a way that is specific to your needs. This blog will provide a forum for the authors to elaborate on UDM and for readers to contribute to the discussion.

To give you an idea of what UDM is about and what you can anticipate reading on this blog, here is a quote from page 8 in the handbook that provides a very basic definition of the UDM strategy.

Urine Drug Monitoring (UDM) is an objective patient-specific pharmacotherapeutic monitoring strategy which logically combines practices and procedures employed in clinical drug trials with current prescribing practices. UDM is a single solution comprised of many complementary parts. Each component scientifically addresses a necessary piece of the drug monitoring equation.

The components of UDM are:

• Laboratory Diagnostics
• Clinical Pharmacology
• Pharmacogenomics and Pharmacogenetics
• Patient Assessment
• Medical Informatics

Thanks for visiting this site. We look forward to hearing from you and responding to your comments in the posts ahead.