Many physician clients who practice pain management ask me whether they need to have their patients provide urine samples during office visits. Some physicians say urine testing is a valuable component of evaluating patient compliance with pain med prescriptions, and monitoring patient safety. Others say urine testing is unreasonably expensive, and provides too little solid information to be worth the cost. While I’m not a doctor, I’ve worked with plenty of doctors who are big trouble for suspected overprescribing or unsafe prescribing of pain or other potentially addictive medications. They are often criticized, after the fact, by law enforcement investigators and Medical Board experts who testify that the lack of urine testing is but one indicator that the doctor was not being sufficient careful to prevent patient “abuse” of prescribed medication. So I say yes, have patients urine tested during office visits. Here’s why:
First, Medical Boards today expect that urine testing will be done. It should be done, both for any clinical value and, sad but true, to protect yourself against unnecessary criticism by investigators. Medical Boards see the value in testing, and so law enforcement agents like sheriff’s deputies, who don’t necessarily have medical training, defer to Medical Board judgment in factoring the presence or absence of testing into the evaluation of the legitimacy and legality of a doctor’s pain practice. It’s a lot easier to point a finger and say, “She doesn’t urine test!” than it is to say, “She’s arguably practicing outside the standard of care, based on guidelines 1-10 and subfactors 27-33!”
Second, even though urine testing typically will show only presence or absence of a drug, and not the level of a drug in a patient’s system, it’s still a worthwhile thing to do, and good information to learn. Urine testing will tell you one of a few things: (1) The patient is taking the drug you have prescribed, or at least that drug is in the patient’s system. If the drug is absent from the patient’s system, but the patient was prescribed a supply and picked up the scrip at the pharmacy, the patient could be diverting the drug. That’s a patient who no longer belongs in your practice. (2) The urine test could reveal the presence of illicit drugs such as cocaine, methamphetamine, or other prescription drugs that you didn’t prescribe. If this shows up, you know the patient has a substance abuse issue, and may be doctor-shopping. You’ll have to take steps to help this patient, too. Failure to evaluate the situation and take appropriate action (including possibly terminating the patient from your practice) will come back to bite you, in an official investigation.
Third, if, say, your patient also turns out to smoke marijuana, and you don’t know it until a urine test shows THC in a patient’s system, you’ll be glad to know that information. The patient should have told you during their initial evaluation. This could factor in to whether you keep them as a patient, for their lack of disclosure – and if you do, you have to establish the terms on which you will henceforth get honest and full information from them. In addition, the patient may be obtaining pain relief from the marijuana; if so, you need to be aware of that, and you need to figure out whether it means the prescription pain medicine should be scaled back or gradually eliminated.
Fourth, though urine testing costs money, criminal defense lawyers cost more, if you’re ever under investigation for suspected unlawful or excessive prescribing. Don’t wait to find out.
In war, they say “know your enemy.” In anti-corruption investigations, the watchword is “know your customer.” And today, it’s also “know your customer’s customer.” In pain management practice, the words to live by are “know your patient,” so that you not only make the right decisions about whether, what, how much and how long to prescribe powerful medication, but if you ever need to, you can defend your decision from a medical, legal, and criminal-investigation standpoint. Urine testing of patients during office visits helps you do that.
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