March 18, 2016 – 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.”
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.
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