**8.1 When and how to test**

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

#### **8.2 Ongoing testing**

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

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medication or illicit drug then subsequent visit UDT's should include tests for those agents. Because of the potential for morbidity from alcohol-medication interactions, it may be necessary to continue to monitor certain patients for ethanol and its metabolites**.**

#### **8.3 Minimum analytical requirements**

When monitoring for opioid medication compliance, the testing method should be able to differentiate between codeine, morphine, hydrocodone, norhydrocodone, and hydromorphone. The test should also be able to differentiate between oxycodone, noroxycodone, and oxymorphone. This will allow the physician to determine that the opiate the patient is taking is in fact the one being prescribed and that the patient is metabolizing the medication properly (Pesce et al., 2010a). A similar case can be made for the testing of benzodiazepines. The method should be able to detect at low concentrations and differentiate between alpha-hydroxyalprazolam, 7-aminoclonazepam, lorazepam, nordiazepam, temazepam, and oxazepam. This will allow the doctor to see that the patient is taking the prescribed benzodiazepine and allay any concerns about doctor shopping. Frequency of UDT should be based on the physician's observations of the patient's behavior as well as suggested guidelines. For those patients whose behavior is not of concern, some guidelines suggest UDT between two and four times per year on a random basis (Chou et al., 2009; Trescot et al., 2006). For those patients with non-compliant behavior or a history of addiction, testing should be done as often as every office visit (Chou et al., 2009; Trescot et al., 2006).
