How much urine drug testing is enough?

There is a single physician's office in North Carolina that derives 82 percent of its revenue from urine drug testing. It would certainly appear that that amount of testing is too much, however, experts speaking on a panel at the National Rx Drug Abuse Summit in Atlanta this week agree that, in some cases, drug testing isn't used often enough among patients that might be at risk of abusing opioids and other prescription drugs.

It begs the question: What is the right amount of urine drug testing? Experts simply don't have an answer.

"We have excessive testing in some sectors, and a lack of testing in others where it is needed," said Michael Gavin, president of PRIUM, a medical intervention organization.

He said physician self referral, in which a provider stands to gain financially from increased testing, is a significant driver of overtesting. A lack of guidelines can also drive over- or underutilization.

In some cases, insurers can be a source of information to help a provider determine best practices because they can distill the range of drug test utilization patterns across many providers from their claims databases. 

And payers do have an incentive to examine urine drug testing, he said. From a cost perspective, less testing might save some upfront costs, but too often an overdose is actually financed by a patient's health insurance.

Tools for stakeholders

Lock-in programs or contracts between patients and providers for opioid prescription drugs can be facilitated through pharmacy benefit managers--the carve-out organizations that manage prescription drugs for an insurer. The programs lock a patient into accessing only one provider and one pharmacy exclusively to head off the possibility of doctor shopping or multiple fills of opioids. A claim generated from another provider or pharmacy would be denied and the locked-in provider would be alerted.

In one particular case tracked by pharmacy benefit manager Express Scripts, a single patient accessed opioid drugs from 17 different prescribers, with 43 prescriptions filled at five different pharmacies. And the case is fairly typical.

"We want to intervene before this happens," said Jo-Ellen Abou Nader, senior director for Express Scripts.

Lock-in programs can help prevent patients from doctor shopping, she said.

Gavin also said patients tend to think of the urine drug tests as punitive. Providers should be thoughtful in their testing strategy and opt to use it as a way to initiate a conversation about treatment goals when a test shows an unexpected result. The key is for the results to be used to influence patient care.

Defaulting to one extreme or the other, providers might choose "willful ignorance" and disregard the significance of an inconsistent urine drug test or instead choose to immediately "fire a patient from their practice" for not adhering to program, he said.