**7. Purposes and costs of UDT**

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

#### **7.1 Cost effectiveness of UDT**

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

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