Universal Precautions

Universal precautions are recommended for use with all patients considered for chronic opioid therapy because illicit drug use is predictive of prescription opioid abuse. A history of multiple providers in the same time period can indicate hazardous use, abuse, or dependence. Therefore these individuals may not be good candidates for chronic opioid therapy.

State Prescription Monitoring

Prescription drug monitoring programs (PDMP) provide a record of controlled substance prescriptions for any patient.  Consider checking the PDMP before prescribing and periodically (every 3-4 months) thereafter.

Urine Drug Screen

The Urine Drug Screen should include an expanded Opioid Panel that includes opioid drugs/metabolites not detected on a standard opioid urine test (which will detect only morphine, codeine, and heroin use). Check for illicit drugs, an expanded opioid panel to detect opioid analgesic medications, and ethyl glucuronide for recent alcohol use.

Gourlay D, Heit H, Kaplan Y. Urine drug testing in clinical practice: the art and science of patient care. PharmaCom Group Inc.; May 2010. Note: document provides education on urine drug screening.

Urine Drug Screens: Points to Remember:

  1. Check urine drug screen with an expanded opioid panel (inclusive of synthetic opioids used in analgesia) before starting chronic opioid therapy.
  2. Standard urine drug screens will only detect heroin, morphine and codeine.
  3. Use point of service tests in the office: dipsticks, cups with drug detection tests.
  4. If a urine drug screen is positive for a drug the patient denies using, send the sample to the laboratory for confirmation (explain that the patient will need to pay for testing).
  5. Use a urine collection container with a temperature strip to assure that the sample is fresh.
  6. Use of illicit drugs is a significant predictor of misuse of opioid pain medications and can be helpful in determining whether opioid therapy is likely to be safe or effective in a patient.