CDC Guidelines Instruct Pain Doctors Not to Test for THC

The Centers for Disease Control and Prevention, in long-awaited guidelines on prescribing opioid medications for pain, gives tepid endorsement for the use of urine testing before and during opioid therapy for pain, despite its statements that, “Urine drug tests do not provide accurate information about how much or what dose of opioids or other drugs a patient took,” and "The clinical evidence review did not find studies evaluating the effectiveness of urine drug screening for risk mitigation during opioid prescribing for pain.”

"Urine drug testing results can be subject to misinterpretation and might sometimes be associated with practices that might harm patients (e.g., stigmatization, inappropriate termination from care),” the guidelines state. Indeed, Cal NORML regularly hears from patients who are terminated from pain management medications because of their use of medical marijuana.

"Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear,” the CDC states. "For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC)...Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety."

"We applaud the CDC's reasoned approach to the use of urine testing and its drawbacks when used on pain patients," said Ellen Komp, Deputy Director of California NORML. "Considering that opioid overdose deaths are significantly lower in states with medical marijuana programs, we are sorry the agency apparently didn't read the letter Elizabeth Warren recently sent to its chief calling for marijuana legalization as a means of dealing with the problem of opiate overdose."

Also from the guidelines:

"Experts agreed that prior to starting opioids for chronic pain and periodically during opioid therapy, clinicians should use urine drug testing to assess for prescribed opioids as well as other controlled substances and illicit drugs that increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin [notice THC is not included.]” The use of "a relatively inexpensive immunoassay panel for commonly prescribed opioids and illicit drugs” was acknowledged but its drawbacks were noted (does not detect synthetic opioids (e.g., fentanyl or methadone) and might not detect semisynthetic opioids (e.g., oxycodone). These panels are often where THC is detected.

"Most experts agreed that urine drug testing at least annually for all patients was reasonable. Some experts noted that this interval might be too long in some cases and too short in others, and that the follow-up interval should be left to the discretion of the clinician. Previous guidelines have recommended more frequent urine drug testing in patients thought to be at higher risk for substance use disorder. However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder."

"Some clinics obtain a urine specimen at every visit, but only send it for testing on a random schedule. Experts noted that in addition to direct costs of urine drug testing, which often are not covered fully by insurance and can be a burden for patients, clinician time is needed to interpret, confirm, and communicate results.”

Read the CDC Guidelines.

Called "the nation's top federal health agency," CDC sought the input of experts to assist in reviewing the evidence and providing perspective on how CDC used the evidence to develop the draft recommendations.

UPDATE 2/26 PM: This response was received from CDC spokesperson Courtney Lenard:

It is prudent for clinicians to restrict use of any medical test to situations when results of the test would be helpful in decisions about patient management. This is particularly important when testing or test results might have unintended negative consequences for patients. Some experts noted that in some cases, positive THC results might have legal or other consequences for patients but might not inform patient care decisions. While CDC is not stating that urine tests for THC should never be used, the guideline recommends that clinicians should only test for substances (including THC) if the clinician knows how he or she would use the results to inform patient management.

Regarding the statement “However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder.”: this statement refers to the difficulty in risk-stratifying patients for urine drug testing, given that most other available tools would not allow clinicians to accurately predict which patients are at low enough risk for substance use disorder that urine drug testing would not be needed.

Also see:
CDC Says Don’t Test Opioid Users for Marijuana National Pain Report 3/26/2016

CDC Guidelines Urge Doctors Not to Test for Marijuana Pain News Network 3/18/16

Federal Government Advises Doctors Against Testing Patients for Marijuana High Times 3/23/16


Testing

I am hopeful that this will help patients under the care of a Pain Management Physician as I am.... I had to sign a contract that stated no medical cannabis or I would be expelled from receiving pain meds..... my Doctor tested me once on my initial visit and has not tested me since (I have been seeing him for just short of a year), he did state to me on my initial visit when I explained why I use cannabis he said go ahead if I want to continue to use cannabis (I thought he was joking/challenging me and to see what happens if I use), but I can only surmise that he was mandated by the hospital to issue these contracts, but as a compassionate/caring physician he will only fulfill the bare essentials of the mandate which is great for my personal situation (but for how long), but I care for all of the other patients who might be under the care of a physician who might not have the same philosophy as my physician has in regards to patients supplementing their pain meds with medical cannabis....
Can someone answer this, does this mean that all Pain management physicians will now not test for THC???

Prohibited

I am also under contract with my pain management clinic except I was warned that any use of cannabis would result in my loss of care. I have been going for there for 4 years and have been tested a dozen times. Though I know cannabis helps, I can't use it until I'm willing to go through withdrawal. California should not be a state where this happens.

Outcomes

The problem of pain doctors drug testing patients has been going on since 2008, see: http://www.canorml.org/paincomplaints.html. We have been pointing out for years that there is no need to test pain patients for THC; they're simply caught up in the cheap and not so pertinent drug screening tests that are used (another thing the CDC criticizes in this report). I don't expect an immediate change in policy by doctors who have been spoon fed the idea of drug testing their patients by companies who profit from it, but I expect many will be reviewing their policies because of the CDC's recommendations.