Urine Toxicology in the Pain Practice

Urine toxicology is actually a big business in many fields of medicine, not just pain management.  A lot of healthcare facilities, critical care units, emergency departments utilize tox screening as well.  As of 2015, it was close to a 5 billion dollar business.  A lot of new companies are offering tox screening services across multiple states, and some have gotten into trouble in terms of having contracts with physicians who were doing more tox screening than was probably medically necessary.

There are different definitions in the tox screening world.  One of the newer ones is presumptive versus definitive urine drug screen testing.  Presumptive testing, also known as point of care testing, just kind of gives us feedback on what drug classes are in a patient’s system, things like morphine metabolites, oxycodone, fentanyl, without actually telling you what metabolite is in the screen. Whereas definitive testing usually gets sent out to a lab to specifically quantify what drugs are in a patient’s urine. 

There are various guidelines available to the practitioner.  The American Society of Interventional Pain Physicians has guidelines, as does the American Society of Anesthesiologists, and the VA.  Some states have guidelines.  The basic thing for primary care to take home about urine tox screening practice is you want to show what’s medically necessary for the patient.  If a patient is a high risk patient, you want to have that seen in your electronic medical record so when you do high-risk tox screening or definitive studies you’re reimbursed for those studies.

A concluding thought regarding tox screening is to document, document, document.  If you’re seeing someone who you think is at high risk for aberrant behavior, document it in your note so that when you send the screen out for definitive studies, it is clear why, and what you’re interested in looking at in that sample.