Patient Centered Urine Drug Testing

Dr. Heit: Number 1, you’re doing a urine test for the patient, not to the patient. It’s to increase communication, not decrease communication. You have to know what question you’re trying to answer with a urine drug test.The test is an important tool but it’s just a tool and you have to know its strength and limitations. The terminology is evolving in the field of urine drug testing. Screening drug testing is now called presumptive testing and confirmation testing is now called definitive testing. The first one is done by immunoassay and the latter, is done by chromatographic studies.

Dr. Gourlay: Urine testing is very good at doing some things but I think we have to be careful that we don’t extend the science of urine drug testing beyond what it’s good for. Really what it’s good for is, as Howard says, opening a dialogue; facilitating a difficult, in some cases impossible, subject to broach with the patient. A urine drug screen gives the opportunity to say to the patient, ‘Your urine drug screen is a little bit surprising to me. Can you help me explain it?’ The nearest analogy I can think of is we can do the hemoglobin A1c to identify whether glycemic control has been good over the past three months; and if a patient says the glycemic control has been good, we still do the urine drug screen. We trust but verify. If the glycemic control from the hemoglobin A1c says your control has not been as good as you think, you use that as an opportunity to motivate change. I think we have to start looking at drug testing in that same fashion.

Dr. Heit: If you have an unexpected positive or negative test result, ask the patient, ‘Could you help me explain these results?’ Give the patient an opportunity to explain, and if the patient is not a candidate for opioid therapy, don’t kick him out of the practice. You could always fire the molecule if you so choose and still care for the patient. We’re holding the pain patient to a much higher standard than anybody else. We call it insulin-dependent diabetes but if the diabetic eats chocolate cake and doesn’t follow the exercise regimen, we don’t call it insulin-addicted diabetes. The pain patient has a higher standard to follow and to be compared to; and so does the prescriber. That is not unfair but it is what it is and you’ve got to deal with it.

Dr. Gourlay: There’s nothing intrinsically therapeutic about collecting urine and testing it, but having a urine drug testing program has on more than one occasion helped the patient make a better choice than they might have made had they not known that they could be involved in urine drug testing. Patients have said that all the time to myself and I’m sure to Howard that, ‘I had a choice to make and it could have been a bad choice and I made a better choice because I didn’t want to discuss this test that may have been positive for something on Monday as a result of what I did on Saturday. So I made a better choice.’ That’s really what I think patient-centered care is about. It’s helping patients make better choices and accept the consequences when they make bad choices.

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