Open Access Open Access  Restricted Access Subscription or Fee Access

Treatment changes following aberrant urine drug test results for patients prescribed chronic opioid therapy

Benjamin J. Morasco, PhD, Erin E. Krebs, MD, MPH, Renee Cavanagh, MS, Stephanie Hyde, MA, Aysha Crain, MSW, Steven K. Dobscha, MD


Background/objective: Urine drug testing (UDT) may be used to help screen for prescription opioid misuse. There are little data available describing usual pain care practices for patients who have aberrant UDT results. The goal of this research was to evaluate the clinical care for patients prescribed chronic opioid therapy (COT) and have an aberrant UDT.

Design: Retrospective cohort study.

Setting: VA Medical Center in the Pacific Northwest.

Participants: Patients with chronic pain who were prescribed COT and had a UDT result that was positive for an illicit or nonprescribed substance.

Main outcome measures: This was an exploratory study designed to document usual care practices.

Results: Participants' (n = 83) mean age was 49.5 (SD = 9.6) and 81.5 percent were male. The most common substances detected on UDT were marijuana (69 percent) or a nonprescribed opioid (25 percent); 18 percent had a UDT positive for two or more substances. Plans to modify treatment were documented in 69 percent of cases. The most common treatment change after aberrant UDT results was instituting more frequent UDTs, which occurred in 43 percent of cases. Clinicians documented plans to alter their opioid prescribing (eg, terminating opioids, requiring more frequent fills, changing opioid dose, or transitioning to another opioid) in 52 percent of cases, but implemented these changes in only 24 percent.

Discussion: Current methods for optimizing treatment after obtaining aberrant UDT results should be enhanced. To improve the utility of UDT to reduce prescription opioid misuse, additional interventions and support for clinicians need to be developed and tested.


urine drug test, prescription opioid misuse, chronic pain, clinical treatment guidelines, primary care

Full Text:



Boudreau D, Von Korff M, Rutter CM, et al.: Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009; 18: 1166-1175.

Kuehn BM: Opioid prescriptions soar: Increase in legitimate use as well as abuse. J Am Med Assoc. 2007; 297: 249-251.

Centers for Disease Control and Prevention: Overdose deaths involving prescription opioids, 2004-2007. Available at Accessed May 27, 2011.

Meltzer EC, Rybin D, Meshesha LZ, et al.: Aberrant drug-related behaviors: Unsystematic documentation does not identify prescription drug use disorder. Pain Med. 2012; 13: 1436-1443.

Morasco BJ, Dobscha SK: Prescription medication misuse and substance use disorder in VA primary care patients with chronic pain. Gen Hosp Psychiatry. 2008; 30: 93-99.

Morasco BJ, Gritzner S, Lewis L, et al.: Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011; 152: 488-497.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10: 113-130.

Katz NP, Sherburne S, Beach M, et al.: Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003; 97: 1097-1102.

Ballantyne JC, Mao J: Opioid therapy for chronic pain. N Engl J Med. 2003; 349: 1943-1953.

Department of Veterans Affairs and Department of Defense: VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. Available at Accessed April 1, 2011.

Adams NJ, Plane MB, Fleming MF, et al.: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001; 22: 791-796.

Bhamb B, Brown D, Hariharan J, et al.: Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin. 2006; 22: 1859- 1865.

Boulanger A, Clark AJ, Squire P, et al.: Chronic pain in Canada: Have we improved our management of chronic noncancer pain? Pain Res Manage. 2007; 12: 39-47.

Morasco BJ, Duckart JP, Dobscha SK: Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. J Gen Int Med. 2011; 26: 965-971.

Bair MJ, Krebs EE: Why is urine drug testing not used more often in practice? Pain Pract. 2010; 10: 493-496.

Starrels JL, Becker WC, Alford DP, et al.: Systematic review: Treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Int Med. 2010; 152: 712-720.

Jensen MP, Karoly P, Braver S: The measurement of clinical pain intensity: A comparison of six methods. Pain. 1986; 27: 117-126.

Von Korff M, Saunders K, Ray GT, et al.: De facto long-term opioid therapy for noncancer pain. Clin J Pain. 2008; 24: 521-527.

Morasco BJ, Duckart JP, Carr TP, et al.: Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010; 151: 625-632.

Reisfield GM, Salazar E, Bertholf RL: Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007; 37: 301-314.

Starrels JL, Fox AD, Kunins HV, et al.: They don't know what they don't know: Internal medicine residents' knowledge and confidence in urine drug test interpretation for patients with chronic pain. J Gen Int Med. 2012; 27: 1521-1527.

Jamison RN, Ross EL, Michna E, et al.: Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial. Pain. 2010; 150: 390-400.

Krebs EE, Bair MJ, Carey TS, et al.: Documentation of pain care processes does not accurately reflect pain management delivered in primary care. J Gen Intern Med. 2010; 25: 194-199.



  • There are currently no refbacks.