**5. Monitoring ethanol use in pain patients**

As stated earlier, alcohol (ethanol) use among pain patients is a significant problem because of the risk for drug-drug interaction with opioid medication. For doctors to understand UDT ethanol results, it is essential that they understand ethanol metabolism and the formation of the ethanol byproducts ethyl glucuronide and ethyl sulfate (Crews et al., 2011a; Crews et al., 2011b; Dahl et al., 2002; Helander & Beck, 2005; Helander et al., 1996; Rosano & Lin, 2008; Schmitt et al., 1997; Stephanson et al., 2002; Wojcik & Hawthorne, 2007; Wurst et al., 2006; Wurst et al., 2004). This is because false positive ethanol results can result from fermentation of glucose from diabetic patient samples (Crews et al., 2011b). Crews et al. reported that about 1/3 of the ethanol positive samples were due to fermentation. Misinterpretation of

Diagnostic Accuracy and Interpretation

**7.2 Social costs of drug abuse** 

pain patients.

**8. Conclusions** 

**8.2 Ongoing testing** 

**8.1 When and how to test** 

of Urine Drug Testing for Pain Patients: An Evidence-Based Approach 39

effective treatment for heroin addiction is the methadone maintenance program, which has an average cost of \$4,700/per patient/per year (Principles of Drug Addiction Treatment: A Research-Based Guide, 2009). Based on these figures, every dollar invested in drug treatment programs yields a return of about 12 times this amount. The goal then should be detecting

There are two aspects of drug abuse in the pain patient population; one is the use of illicit drugs, and the other more prevalent aspect is abuse of the prescribed and non-prescribed medications. Combined, these two facets of abuse may approach 20-30% of the patients on chronic opioid therapy. Using this percentage of patients and factoring the \$56,000/patient cost, this means that on average each of these patients may actually be costing society and insurers \$16,800 more annually than what is estimated by only calculating costs of office visits and medications. If clinical UDT is performed 2-4 times per year for each patient reimbursed at \$500 per UDT, this represents a cost of \$1000-\$2000 per patient per year. This is in contrast to the \$16,800 referenced above. It seems clear that using UDT to detect these patients should

In light of the fact that providing the highest standard of care is one of the basic tenets of the medical profession, it is important to note that several studies have shown that untreated opioid-abusing patients have significantly higher societal cost (Wall et al., 2000) and mortality rate (between 2 and 10 times) than the comparative general population (Hall et al., 2008; Oyefeso et al., 1999). Based on this data alone, the use of UDT should be justified for

Pain is a complex disease and chronic opioid therapy is one of the treatments of choice. Urine drug testing is one of the ways to measure patient adherence to the treatment regimen. At the intake office visit it is important for the physician to be able to make immediate assessment of the patient to validate their reported history and to determine the overt presence of illicit drugs or non-prescribed medications. Either a POC device or inoffice immunoassay analyzer should be used for this purpose. A portion of the patient's urine specimen should be sent to a reference laboratory for analysis using lower cutoffs and a much extended test menu such as those listed in Tables 1 and 2. As stated earlier, this will give the physician further confidence that the patient's history is valid and provide measurable evidence for informed clinical decision making. In addition, alcohol use, which

At subsequent visits UDT will provide the physician with evidence of patient compliance with prescribed medications (West et al., 2010a) and eliminate the potential for abuse of non-prescribed medications or illicit drugs (Pesce et al., 2010b). For this purpose, depending upon clinical judgment, the test menu does not have to be quite as extensive. Tests for rarely-observed illicit drugs such as MDMA and PCP may not be included. Similarly, tests for rarely-prescribed or removed medications such as propoxyphene may not be included. If intake visit UDT showed that the patient was observed to be taking a non-prescribed

cannot easily be detected by the POC devices, can be identified as a risk factor.

significantly reduce the cost of care as well as the costs to society (Wall et al., 2000).

untreated drug abuse. Urine drug testing helps accomplish this goal.

these results can have grave consequences as doctors may establish a contract with a patient that he or she abstain from any alcohol use while being treated with opioid medication; therefore, a positive finding for alcohol use can result in dismissal from the practice (Federal Register, 2004).
