A team of interdisciplinary clinicians specialized in pain management and substance abuse have established new guidelines for the use of urine drug monitoring (UDM) in risk stratification and the prevention of opioid use disorder, overdose, and diversion.

A panel consisting of clinicians with expertise in substance use disorders, pain management, and primary care identified 6 guidelines for UDM in patients prescribed opioid analgesics to manage chronic pain. A total of 85 studies regarding UDM were analyzed.

As UDM has high accuracy, the panelists recommend definitive testing (eg, chromatography-based testing) in this patient population. Initially, presumptive testing (eg, immunoassays) may be required because of payer or institutional policies.

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The panel suggested that the most effective opioid risk stratification regimen should be based on a patient’s clinical history as well as previous UDM, prescription drug monitoring program data, and results from risk assessment tools. For patients prescribed opioid therapy for managing chronic pain, the investigators suggest performing UDM at baseline. Following this baseline measurement, patients considered to be at low risk for opioid use disorder should be monitored once per year, individuals at moderate risk, ≥2 times per year, and high-risk patients should be monitored ≥3 times per year.

Class-specific immunoassays in the primary care setting can have limited sensitivity and specificity, and may be misinterpreted. In addition, the panelists commented that the inaccuracies related to immunoassays may ultimately increase costs incurred by further treatments.

As illegal cannabis use was found to be associated with opioid misuse and/or substance use disorders and considering that “patients may divert prescription opioids to purchase cannabis,” the panelists recommended screening for cannabis in patients with chronic pain.

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Argoff CE, Alford DP, Fudin J, et al. Rational urine drug monitoring in patients receiving opioids for chronic pain: Consensus recommendations. Pain Med [published online December 1, 2017]. doi:10.1093/pm/pnx285.