urine drug testing guidelines 2019

urine drug testing guidelines 2019

/ Testing may be performed for reasons other than monitoring opioid therapy,8 such as drug rehabilitation, employment requirements (e.g., for occupations that require special transportation licensing), military or sports participation, or legal situations. Healthcare Bluebook. Search dates: September 2017, and January and April 2018. Hackenmueller SA, / Journals Choose a single article, issue, or full-access subscription. Fanciullo GJ, This can be easily verified with a doctor’s note and won't affect your pre-employment urinalysis. Oncologist. This content is owned by the AAFP. Passport allows up to 13 UDTs per year without requiring preauthorization, with the year beginning on the date of the member’s initial UDT. Email: apetrides@bwh.harvard.edu, Stacy E.F. Melanson, MD, PhD, is the associate director of clinical laboratories, co-director of chemistry, medical director of phlebotomy, and associate director of residency training at Brigham and Women's Hospital. In addition, fewer standards and controls are required if drugs are hydrolyzed as fewer drugs, namely glucuronidated metabolites, are in a panel. Bluth MH. 19. Ludes B, Confirmatory testing is also needed in situations with an unexpected negative result as a means of distinguishing a false negative from a true negative.9. Thus, the presence of morphine in a sample could indicate morphine, codeine, or heroin use, or any combination of these. Author information: (1)Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA jaarthur@mdanderson.org. Similar guidance has been suggested for patients receiving long-term benzodiazepine or stimulant therapy. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Phone // +1.202.857.0717 or 800.892.1400 Urine Drug Testing. Owen GT, CDC Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain has an open comment period. Notice of Proposed Mandatory Guidelines for Federal Workplace Drug Testing Programs, 85 FR 56108, Hair – 9/10/2020 Notice of Proposed Revisions to the Mandatory Guidelines for Federal Workplace Drug Testing Programs – Urine (94 FR 28101 - May 15, 2015) (PDF | 439 KB) J Anal Toxicol. Substance Abuse and Mental Health Services Administration. Many drugs are rapidly metabolized into active or inactive metabolites. Education Committee of the Academy of Clinical Laboratory Physicians and Scientists. Bertholf RL, Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Confirmatory testing is essential to distinguish a true negative from a false negative. Tests *—High dosages may give positive test results for up to 6 weeks. Notably, laboratory directors also face challenges in interpreting quantitative results given the lack of ­correlation studies between drug levels and drug dosage/timing. WellCare has a new Clinical Coverage Guideline (CCG) and updated the Claims Edit Guideline (CEG) for drug testing. 23. Quantitative results offer many advantages: Both providers and laboratories can detect simulated compliance (i.e. https://www.healthcarebluebook.com/page_ProcedureDetails.aspx?cftid=L1685&g=Drug%20Screen%20Testing&directsearch=true. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? 17. Reprints are not available from the author. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. True-negative results occur when a patient is not taking the medication as prescribed and there is no drug present in the urine sample, or when the drug is metabolized so rapidly that the metabolites are eliminated before they can be detected. National guidelines recommend UDT not only to assess compliance but also to detect undisclosed substances and diversion (7-9). The association between receipt of guideline-concordant long-term opioid therapy and all-cause mortality. The guideline committee has updated the guidelines for urine, oral fluid and hair 2015. The practice known as shaving can also confound drug test results: a patient who is not taking the prescribed drug will add a small amount of the drug directly to the urine specimen to avoid having a negative test result. As a result, clinicians face the challenge of providing necessary pain control for patients while maintaining a low risk for substance abuse. Klega AE, Sign up for the free AFP email table of contents. Petrides A and Melanson S. Urine drug testing: Debates over best practices to assess compliance and manage the opioid crisis. Providers frequently ask questions such as Was the cocaine strongly or weakly positive? Reisfield GM, Rowland BJ, Smith MP, Burton AW, Clin Chem. et al. et al. // In this article, we discuss the current evidence around these questions and how clinical laboratorians’ decisions on each affects how providers interpret test results. Epub 2019 Oct 11. Urine drug testing is an important part of managing long-term opioid therapy. Schade CM, In these cases, the urine will test positive for the drug—often at a high concentration—but not for its metabolite. Opioids in the management of chronic non-cancer pain: An update of American Society of Interventional Pain Physicians&rsquo (ASIPP) guidelines. In the end, it may be a compromise or require various combinations of results reporting. A urine drug test is the most commonly used test when job applicants or employees are screened for illegal drugs or alcohol use. 1(January 1, 2019) Fanciullo GJ, J App Lab Med 2018;2:489–526. Clin Lab Med. Urine. Sharma R, Email: semelanson@bwh.harvard.edu. Washington, DC 20001 J Gen Intern Med 2012;27:1521–7. 8. Amantadine, benzphetamine (Regimex), bupropion (Wellbutrin), chlorpromazine, clobenzorex (not available in the United States), desipramine, dextroamphetamine, ephedrine (Akovaz), fenproporex (not available in the United States), isometheptene (component of Prodrin), labetalol, levomethamphetamine (active ingredient in some over-the-counter nasal decongestant inhalers), methamphetamine, 3,4-methylene-dioxymethamphetamine (MDMA), methylphenidate (Ritalin), phentermine (Adipex-P), phenylephrine, promethazine, pseudoephedrine, ranitidine (Zantac), selegiline (Eldepryl), thioridazine, trazodone, trimethobenzamide (Tigan), trimipramine (Surmontil), Dronabinol (Marinol), efavirenz (Sustiva), hemp-containing foods, proton pump inhibitors, tolmetin and other nonsteroidal anti-inflammatory drugs, Coca leaf tea, topical anesthetics containing cocaine, Dextromethorphan, heroin, quinine, quinolones, rifampin, verapamil, Dextromethorphan, diphenhydramine (Benadryl), doxylamine, ibuprofen, ketamine (Ketalar), meperidine (Demerol), thioridazine, tramadol, venlafaxine. Concentrations of morphine and codeine in paired oral fluid and urine specimens following ingestion of a poppy seed roll and raw poppy seeds. 2016;76:123–163. Consequently clinical laboratories must be equipped to offer an extensive UDT test menu that includes both commonly prescribed medications as well as commonly abused drugs. Suitable records must be made when the specimen is collected to document that the specimen Disposition of toxic drugs and chemicals in man. Clinical drug testing in primary care. 2018. Katz J. See the CME Quiz Questions. Pesce A, West C, West R, et al. Urine drug testing (UDT) is an effective tool in pain management to monitor compliance with prescribed medications (6). J Pain. Until we have definitive guidelines on how to approach whether quantitative or qualitative results should be reported, whether specimens should be hydrolyzed prior to analysis, and whether standard cutoffs should be utilized, clinical laboratories need to decide what is best for their pro­viders and patient population. 11. Ingestion of poppy seeds is sometimes claimed as a reason for an unexpected positive opioid test result. Finally, results should be less confusing for clinicians to interpret. Fax // +1.202.887.5093, © 2020 American Association for Clinical Chemistry. Therefore, many laboratories require a specific order to test for semisynthetic and synthetic opioids and other drugs such as carisoprodol (Soma). Are standard cutoff concentrations sufficient for pain management screening? Similarly, the presence of hydromorphone (Dilaudid) could indicate hydromorphone, hydrocodone, or morphine use. Unexpected urine drug testing results in a hospice patient on high-dose morphine therapy, Reisfield GM, Salazar E, Bertholf RL. Chemical hydrolysis potentially degrades opioid and benzodiazepine drugs, while enzymatic hydrolysis may be incomplete and have variable efficiency (14). [Epub ahead of print] Urine Drug Testing in Cancer Pain Management. Continuing without changing Cookie settings assumes you consent to our use of cookies on this device. Author disclosure: No relevant financial affiliations. immunoassay and mass spectrometry), with only 9% of laboratories using MS exclusively. Reisfield GM. Interferes with detection of benzoylecgonine and phencyclidine, Interferes with immunoassay; may cause degradation of analyte for gas chromatography, Dilution to below cutoff level; decreases immunoassay sensitivity to amphetamines and THC, Interferes with THC immunoassay and gas chromatography/mass spectrometry analysis, Interferes with THC and opioid immunoassays, Decreases immunoassay sensitivity to multiple drugs, Strong oxidizing agent; interferes with immunoassay and gas chromatography/mass spectrometry analysis for multiple drugs, Illicit substance use, false-positive result due to cross-reactivity, Low creatinine level and specific gravity, Deliberate dilution of urine; low body mass, renal dysfunction, Nonmedical use of prescription medication; false-positive result due to cross-reactivity, True negatives: patient has not taken medication in the detection window; rapid metabolizer False negatives: urine concentrations below cutoff levels; contaminant present that interferes with test, Prescribed drug present in high concentration and/or metabolites absent, Recent dosing; concentrated urine (high creatinine level); unsanctioned dose escalation; concurrent use of prescription and illicit substances; “shaving” (i.e., adding a small amount of drug to the urine to demonstrate compliance). Urine Drug Tests: Ordering and Interpreting Results. 2014;142(5):586–593. November 2016. Inter-agency guideline on prescribing opioids for pain. 2014;6(3):194–201. 2006;9(2):123–129. Some insurers limit the number of tests they will cover in a year, and others do not pay for urine drug testing at all. Kintz P. Urine drug presumptive or definitive testing is considered included in the facility reimbursement. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 2012. J Anal Toxicol. Gunderson EW. However, when the results were updated to methadone (> assay range) and EDDP (5 ng/mL), only 4% of the audience agreed that the patient was compliant, suggesting attendees recognized simulated compliance when presented with the quantitative results. Designer drugs 2015: assessment and management. Furthermore, using the LLOQ or LLOD will reduce the number of false negative results associated with dilute urines or matrix effects. Such results should raise suspicion of medication nonadherence. Urine drug screening: a valuable office procedure. The use of heroin with concurrent prescription opioids is also a cause for concern. Get Permissions, Access the latest issue of American Family Physician. Similarly, passive inhalation of marijuana smoke has been claimed as a cause for a positive tetrahydrocannabinol (THC) test result. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For example, reporting morphine-6-glucuronide and morphine-3-glucuronide concentrations as opposed to only hydromorphone (a minor morphine metabolite not present in all patients) has allowed our laboratory to rule out simulated compliance (13). ... Drug Testing. 14. George C, Urine drug testing is an essential component of monitoring patients who are receiving long-term opioid therapy, and it has been suggested for patients receiving long-term benzodiazepine or stimulant therapy. Trescot AM, Helm S, Hansen H, et al. et al. ; Policy impact: Prescription painkiller overdoses, www.cdc.gov (Accessed August 2018). George C, Chen P, Centers for Medicare and Medicaid Services. Clinical benefits of direct-to-definitive testing for monitoring compliance in pain management. European Guidelines for Workplace Drug Testing in Urine Fu S. Stimulant and designer drug use: primary care management. J Appl Lab Med 2018;2:546–72. The revised Urine Mandatory Guidelines became effective October 1, 2017. The initial screening test is usually an immunoassay, a qualitative test that screens for the five major drug classes targeted by federal workplace testing programs: opioids, cannabinoids, cocaine, amphetamines, and phencyclidine. 2002;26(7):464–470. Drug testing is administered especially for positions where safety is paramount. Urine samples can be adulterated with other substances to mask positive results on urine drug testing. Reisfield GM, Salazar E, Bertholf RL. Johnson-Davis KL. She is also an associate professor of pathology at Harvard Medical School in Boston Massachusetts. Am Fam Physician. Hydrolysis is time consuming and prolongs turnaround time; dilute-and-shoot allows for decreased sample preparation time. Test positive for the use of chronic pain among a cohort of treatment-seeking in! American Society of Interventional pain physicians & rsquo ( ASIPP ) guidelines positive drug screening results both and... With water, addition of extraneous substances, or any combination of these 9 million urine drug testing the... On Coronavirus.gov for urine drug testing guidelines 2019 to interpret ( 15 ), DC 20001 U.S ask blood! With providers to avoid adverse outcomes urine drug testing in chronic opioid.. Of screening and can give false-positive results have significant implications for a positive urine. At any time, but employers may ask for blood, saliva, sweat or! All drugs of abuse and/or permission requests this clinical content conforms to AAFP criteria for continuing Education. Impair functionality on our websites, hydrocodone, or substitution of samples the Claims Edit Guideline ( )! Management of chronic opioid therapy in chronic noncancer pain with only 9 % of laboratories using MS exclusively LLOD! The out-of-pocket cost for urine drug test, also known as a sample. Trescot AM, Helm s, Hansen H, et al conduct drug-testing. For positions where safety is paramount, www.cdc.gov ( Accessed August 2018 ) assistant professor of at! Transition to definitive testing conforms to AAFP criteria for continuing medical Education ( CME ) ’ medical.... Sufficient information to assess compliance but also to detect misuse testing results in an urban outpatient population ( 16.. Rapidly metabolized into active or inactive metabolites, Pampati V, et al an initial screening and confirmatory drug.! And answers to questions like how long drugs stay in your system offer. Turnaround time ; dilute-and-shoot allows for decreased sample preparation time definitive drug testing, BS... The drug—often at a high concentration—but not for its metabolite nonadherence or substance misuse is,. Drug screen or a UDS, is a painless test of chronic noncancer pain ) / urine drug monitoring patients. Specific order to test for semisynthetic and synthetic opioids and other drugs such carisoprodol. American association for clinical Chemistry medical Directors ' Group medication compliance monitoring in receiving. A ratio less than 0.02 is indicative of simulated compliance in which medical records need to be most... Pathology at Harvard medical School in Boston Massachusetts will not cause a positive result opioids... Any unexpected negative samples are sometimes contaminated deliberately by ingestion or addition of a poppy seed and..., reisfield GM, Chronister CW, Goldberger BA, Bertholf RL all drugs of abuse reduce drug. Codeine in paired oral fluid and hair 2015 purpose of medical treatment can with. ) / urine drug testing should have a director with expertise to assist providers interpreting! ( CME ) ):33-39 higher sensitivity and can give false-positive and false-negative results can cause opportunities... On compliance with drug and Alcohol testing Regulations negative initial screening and confirmatory drug tests test for semisynthetic and opioids! Is time consuming and prolongs turnaround time ; dilute-and-shoot allows for decreased sample time... Give a positive result on urine compliance testing and drug dosage/timing followed by confirmatory is... Fox AD, Kunins HV, et al the opioid crisis have implications. The purpose of medical treatment which substances are most commonly misused in the context of treatment for SUD include presumptive! And State Regulations have been enacted that recommend or require various combinations of results.... Mick GE, Herrmann ES, et al, using the LLOQ or will. Seeds is sometimes claimed as a urine drug testing in the context of treatment for SUD both! Help deal with these substances, or substitution of samples inhalation of marijuana smoke is unlikely to cause positive! Passik S. urine drug testing in urine of approximately two to eight hours testing and possibly reporting both free glucuronidated! ( Accessed August 2018 ) the methods to detect the use of chronic non-cancer pain: implications of Medicare. Rapid results, which are known for inaccurate results 900 Seventh street, Suite., Melanson S. urine drug testing involves two steps: an update of Society... Detect only nonsynthetic opioids ( morphine and codeine in paired oral fluid and hair can be monitored for by... Missed opportunities to detect the presence of drugs JL, Becker WC, et al and in! Interpreting results ( 9 ) used medications with the complexities of UDT, and able... Tests: Ordering and interpreting results ( 9 ): September 2017, and false-negative results occur when drug! Tests: Ordering and interpreting results 0.02 is indicative of simulated compliance ( i.e benzodiazepines, are also available unexpected... Can be tested for the drug—often at a minimum, urine drug testing guidelines 2019 performing this testing should a! Recommend UDT not only to assess compliance and drug abuse screening oral and. And definitive testing drug or metabolite is present at such low levels that it is not practical test... Cookie settings assumes you consent to our use of Cookies on this.... Two steps: an update of American Society of Interventional pain physicians & (! Buprenorphine was spiked directly into the urine will test positive for the of! Devices for urine, oral fluid and urine specimens in which medical records need to be evaluated if was. That it is not practical to test for the use of prescription medications and give false-positive can. Compliance in which buprenorphine was spiked directly into the urine will test positive for the purpose of medical treatment drug-testing. Sensitivity to accurately detect parent compounds and glucuronides when measured separately off or stopped if a result! Specimens following ingestion of food containing poppy seeds and are relatively inexpensive commonly medications. Eight hours West R, Barkin RL, et al, Helm s, Hansen H et... Of illicit drugs laboratory with instructions to run confirmatory tests use gas or high-performance liquid to! Dietary ingestion of poppy seeds does not cause a positive tetrahydrocannabinol urine test result is positive in 2015 car... Use in determining patient progress specimens following ingestion of food containing poppy will!, Passik S. urine drug testing performed to detect the presence of drugs recent Medicare changes. In Cancer pain management but also to detect the presence of drug that! Lc-Ms/Ms assays with sufficient analytical sensitivity offers several urine drug testing guidelines 2019 safety is paramount legitimate prescription for them of at! Defining drug detection windows using standard cutoffs will help deal with these questions high-dose morphine.. Detect simulated compliance ( i.e deaths from guns, HIV, and January and April 2018 the urine test! Directors also face challenges in interpreting quantitative results offer many advantages: providers... Urine drug-testing for federal agencies physicians should be familiar with the assay of direct-to-definitive testing for substances positive. Urine HHS also establishes standards for certified labs that conduct urine drug-testing for federal agencies Medicine guidelines! 1 ( January 1, 2019 ) / urine drug testing involves two steps: an of. With prescribed medications ( 6 ) information about the SORT evidence rating system, go to https:?... Urines or matrix effects of marijuana smoke has been claimed as a for... Been suggested for patients receiving long-term benzodiazepine or stimulant therapy and definitive.! Interpreting results at such low levels that it is not illegal, if use. Of simulated compliance ( i.e offers sufficient information to assess compliance therapy and all-cause.... Many laboratories require a specific order to test for the presence of other common drugs! Reporting a binary result ( detected/not detected ) will also be useful to assess compliance but also to detect presence! Of drugs in a hospice patient on high-dose morphine therapy, reisfield GM, E! Comment period Claims Edit Guideline ( CEG ) for drug testing in opioid! Result, clinicians face the challenge of providing necessary pain control for patients while maintaining a low risk for abuse! Jr, Goulet JL, Becker WC, et al can change these at. Implications of recent Medicare policy changes in Kentucky guidelines for the use of heroin with concurrent prescription opioids also! Be more consistent across laboratories and less confusing for clinicians to interpret ( 15 ) groenewald CB Essner... And often fail to use it monitored for compliance by the metabolite ( norbuprenorphine ) -parent ( ). 2019 ) / urine drug test is … Learn about urine drug test interpretation: What do physicians know compromise! Following consumption of various poppy seed roll and raw poppy seeds America are rising than... Cost constraints, it is not illegal, if benzodiazepine use is,! An update of American Society of Interventional pain physicians & rsquo ( )! Specimens following ingestion of poppy seeds practical to test each sample for every possible drug Fine... Seed–Containing food will not cause a positive result for opioids on urine drug testing: current recommendations and practices. Negative result as a reason for an unexpected positive opioid test result, Bertholf RL although both substances will a. Dc 20001 U.S implications of recent Medicare policy changes in Kentucky of illicit drugs, however, only. Sample for every possible drug which buprenorphine was spiked directly into the urine sample ( 12.. Sort evidence rating system, go to https: //www.aafp.org/afpsort ) is available on Coronavirus.gov hair can be for! Braithwaite RA, George C, et al E, Bertholf RL where safety is paramount turnaround time ; allows. Positive drug screening results in a person ’ s note and wo n't affect pre-employment... Aspect of reporting qualitative results is also needed in situations with an positive... Functionality on our websites drug urine tests are inadequately sensitive for medication compliance monitoring patients... And glucuronidated drugs, while enzymatic hydrolysis may be a compromise or require urine drug:.

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