**8. Conclusions**

38 Toxicity and Drug Testing

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

Urine drug testing must be tailored to fit the pain patient's clinical history. For the intake visit, the patient is advised as to the necessity for UDT and is typically requested to provide a urine specimen. If the patient fails to do this, he or she may be immediately dismissed from the practice. In some practices, the urine specimen is tested by a POC device at the time of the appointment and the results are compared to the patient reported history. If necessary, discrepancies are discussed. As a matter of course, a portion of the POC urine sample is sent to the reference laboratory to confirm the POC test results, test for additional medications, and, at the discretion of the physician, to test for the prescribed medications, non-prescribed medications and illicit drugs at lower cutoff levels than those provided by the POC test. For many established pain patients, quarterly or semi-annual UDT is considered appropriate. It is best if this is done on a random basis. The strongest recommendation for doing UDT is adding additional medications to the regimen or changing medications. Urine drug testing may also be administered if a patient changes their behavior or exhibits addiction tendencies such as complaining of running out of medications early (Chou et al., 2009; Trescot et al., 2006). Testing may be conducted as frequently as every office visit for some patients who exhibit unusual behavior, have a history of abuse, or if illicit or nonprescription drugs were found to be present on a previous test. Gourlay, D. & Heit, H.

As stated earlier, the purpose of UDT (as well as the relative costs) may be broken down into three components: testing prescribed medications for compliance; testing for nonprescribed medications; and testing for illicit drugs. At the time when the forensic model of drug testing was instituted the vast majority of people who died from drugs died from the use of illicit drugs. At this point in time more people die from prescription medications than by illicit drugs (Hall et al., 2008; Krausz et al., 1996; Okie, 2010). There are now 13 or more classes of drugs that are used to treat pain. Pain patients are on an average using three of these drugs (Kuehn, 2007; Okie, 2010). Therefore, for every 100 patients, 300 confirmations by mass spectroscopy are required. This is more than a 100-fold increase in the number of tests needed to serve this patient population compared to workplace testing. This represents a radical change in UDT model from the forensic model used at the time when the purpose of drug testing was to root out the one or two percent of drug-using professional drivers. It is important that legislators and payors for UDT services understand the shift from the forensic UDT model to the clinical model. Currently the insurance reimbursement codes and categories do not accurately reflect the costs associated with these new clinical drug testing

It is also important to discuss the cost-effectiveness of UDT. The National Institute on Drug Abuse (NIDA) states that the cost of not treating an addict is \$56,000/year. An example of

Register, 2004).

(2010a).

**7. Purposes and costs of UDT** 

**7.1 Cost effectiveness of UDT** 

requirements (*Cpt Current Procedural Technology*, 2010).

**6. When to use UDT** 
