Good afternoon, and thank you for joining us today. My name is Anne Burns, and I have the distinct pleasure of serving as the moderator for today's webinar. On behalf of the American Pharmacists Association and APHA's Pain, Palliative Care, and Addiction SIG, we would like to welcome you to today's webinar entitled Appropriate Interpretation of Urine Drug Screen Results. Before we get started, I have a few announcements. Please note under the handout section, you will find a copy of the handouts to follow along and prepare your responses for the upcoming pre- and post-assessment questions. Please refrain from raising your hands during the presentation. We will not unmute individuals' audio to answer questions orally. You may submit your questions at any time during the presentation using the chat box provided. Toward the end of the webinar, we will provide an attendance code. You will need this code to complete the training materials required to obtain one contact hour of CPE credit for pharmacists. Also please note that CPE credit is available only for this live webinar. There is no home study for this particular webinar. We will provide instructions toward the end of the webinar as to how you may obtain credit for attending this event. Our first speaker, Dr. Emily Lapine, is a clinical assistant professor at Binghamton University School of Pharmacy and Pharmaceutical Sciences. Dr. Lapine maintains an ambulatory care clinical practice site at Lord's Pain Care, where she inaugurated collaborative drug therapy management services. She specializes in the treatment of chronic pain, substance use disorder, and psychiatric illness. Her professional and research interests include opioid and non-opioid pharmacotherapy and the integration of behavioral health and substance use disorder treatment with pain management services. Dr. Lapine currently serves as the coordinator for APHA's Pain Palliative Care and Addiction Special Interest Group. Our next speaker is Dr. Mark Garofali. He is a faculty member of the West Virginia University School of Pharmacy, a faculty member of West Virginia University School of Medicine Pain Fellowship Program, and a medicine pain and addiction pharmacist. Mark is known as the pain guy to many of his colleagues and has been a 2021 TED Talker, CDC grant reviewer, criminal civil expert witness, seasoned CPE developer and presenter, and is the host of the Pain Pod. I'm delighted to welcome our two qualified speakers for this special event. Our speakers, Dr. Mark Garofali and Emily Lapine, do not have any financial disclosures to declare. This webinar is achievable through support from the Provider Clinical Support System. And the overarching goal of PCSS, as we call it, is to train health care professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. Here are the learning objectives for today's webinar. I'll give you just a few moments to read through them before moving on to the next slide. As mentioned, this learning activity was developed by the American Pharmacists Association and supported by a grant from the Provider Clinical Support System. The views expressed in written conference materials or publications and by speakers and the moderator do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial names, practices, or organizations imply endorsement by the U.S. government. Now let's move on to our pre-assessment questions. We'll allow about 10 seconds to collect responses, which we're going to conduct by a poll before advancing to the next question. These questions will be repeated at the end of this presentation to measure outcomes. Your participation is greatly appreciated. So here's our first question. Which of the following medications can possibly produce a false positive urine drug screening for methadone? I'll give you just a couple of seconds. Okay, closing it out. Moving to our second question, a patient using morphine may also show a positive result for morphine. For which of the following on a confirmatory urine drug test? Okay, some interesting responses. Moving on to question three. Urine drug monitoring should be performed for low-risk patients a minimum of every Okay, again, we'll revisit these questions at the end of the webinar and now it is my great pleasure to turn the program over to Dr. Emily. Thank you and for the wonderful introduction to get us started. There is a list here of the 12 recommendations from the newly updated CDC, opioid prescribing guidelines updated in 2022. We've highlighted toxicology, urine drug testing as that is what we are going to be reviewing this afternoon. So, in terms of urine drug testing, or urine drug monitoring. Our goals are to improve medication adherence. Prevent medication misuse or diversion. And even detect medication misuse or diversion. So you can see here, the little clip is of a urine drug screen point of care testing and Mark will get into what the various tests look for in future slides. But you may see here that a urine drug screen is looking for some various substances, controlled substances that a patient in a pain clinic may be prescribed and by performing the urine drug monitoring, we can identify whether or not a patient is adhering to the medication metabolizing the medication as we would have expected if they're if they're urine drug screen results is negative. And we would have thought it would have been positive for a substance. What does that mean? Or even vice versa? Is it positive for something that we would have expected it to be negative? So, keep these goals in mind when we talk about how to perform you're in drug monitoring and how to analyze the results. So, when we think about frequency, how often should somebody should a provider should a clinician perform urine drug monitoring it at a minimum? We should be monitoring at least annually, at least every 12 months for what we would consider a low risk patient. And when we talk about risk, we talk about risk of adverse effects or consequences of the medications that the patient may be prescribed. However, there is evidence to support that monitoring should be done at every appointment, regardless of the patient's risk. There's evidence out there to suggest random urine drug screening, not necessarily in an effort to try and catch a patient in a lie. But instead, just to see what is happening on a random day when the patient may not be prepared for providing a urine sample. So, as the risk increases, the frequency, or how often we want to perform, you're in drug monitoring increases. So, how do we define risk? So, the risks that are possible risks that could be that we could see in a patient are past or current use of illicit substances. Especially when we're talking about pain in psychiatric illness, substance use disorder, sometimes patients self treat with medications, whether those are prescription or illicit or other various substances. Depending upon the opioid medication that's being used, some opioid medications are more potent have an increased risk of abuse potential or increased risk of diversion compared to other opioids. When we think about weak versus strong, so, looking at the patient's medical history and identifying whether or not they have used past substances, reviewing the prescription drug monitoring program. So, identifying what prescriptions a patient is filling from their pharmacy, where are they filling them? And how are they paying for them? So, patients who are using a variety of concomitant medications, such as benzodiazepines or non benzodiazepine receptor agonists, such as Zalapone, isoproclone. In addition to opioid medications can certainly increase a patient's risk of adverse effects can increase a patient's risk of developing a possible substance use disorder. There are various screening tools that are available to help you quantify a patient's risk. And I've listed some of those here on the slide for you, such as the drug abuse screening task, which tends to be commonly used in my particular clinic. But we also have the opioid risk tool and then screener and opioid assessment for patients with pain, and these can help to quantify a patient's risk for experiencing adverse effects, or for potentially developing a substance use disorder. And we would be looking at this risk to identify how frequently we should be performing urine drug monitoring. So, when we're thinking about urine drug screening, so you're in drug screening, being our point of care testing, there are some various strategies to keep in mind. Typically, in a pain management clinic, or in a substance use disorder clinic, there is a patient and a provider agreement. So there is sometimes it may be referred to as a pain management contract, but it's a various. Various items outlined into what the patient may be required or not required to do. So things may be that may be included as a provision could be that the patient agrees to urine drug monitoring. Patient agrees to pill counts patient agrees to not seek opioid prescriptions or other control substance prescriptions from providers outside of this practice. So, having these agreements in place, having them signed by the patient reviewing them can certainly help to hold some accountability having the urine drug screens be random or scheduled. So, you can have a patient provide a urine sample randomly at their appointments, or maybe you call them and you say, hey, we need you to come in for a random urine drug screen and a random pill count. And educating the patient on the purpose of urine drug monitoring is always going to be important because we don't want the patient to think that they're doing something wrong. Or we're trying to catch them, or we think they're a drug addict as they may. They may complain to us about, but if we educate the purpose, the goals that we're talking about. We can see some improved compliance. So, when we go to perform, you're in drug screening things to think about are providing the patient with a private bathroom. Oftentimes, you'll see in these bathrooms, the ability to turn off running water. In that way, the patient cannot dilute the sample with water. Staining the toilet bowl water blue, so patients can't scoop water up out of the toilet to dilute their sample using a urine specimen comp that has a temperature strip. That's going to certainly help us because what we know what the temperature of urine should be. Having the drug test panel look at your creatinine and specific gravity to give us a better idea of, is this actual urine? Is this diluted or has this been altered with a different substance? And another thing to look at is just looking at the sample itself. The normal urine color is going to be this light yellow. If we see that it's very light, almost clear, or almost as if there's no yellow present, it could potentially give us an idea that maybe this is a diluted urine sample. Those are things to keep in mind when we're performing urine drug screening. All right, so as we transgress here from speaker to speaker, hello, I'm Mark. Feel free to take any urine breaks, potty breaks as needed along the way, but rush back because we got a lot to cover, right? Thank you Emily for that intro material there. Sometimes the basics are the most important. I know I myself watch my own urine as a patient more than some of those $5,000 toilets available in other continents because there's a lot to be said for what comes out of us as humans. On top of that, words matter. We all hear that a lot in society anymore and it's always very important. But what we're looking at here is, you want to talk about the basics? Well, when it comes to urine drug monitoring, the basics really matter. So much so that things are labeled incorrectly. Not the medications, don't worry, let's not rile up the FDA, right? So urine drug monitoring is a generalized umbrella term when we're talking about all things urine drug screening and urine drug testing. There are significant differences, but the urine drug screenings, typically the cups, as we'll conversationally say, oftentimes or even those screenings are labeled as tests. And there's differences here, as we'll cover here within this chart overall. But again, urine drug monitoring, the overall umbrella, and then the nuances, major ones, between UDS or urine drug screening and UDT, urine drug testing. So the cup, as I already alluded to, that's the immunoassay screen. Now, fun fact, general quiz here, this is not a poll question, but how many folks are fluent with immunoassays these days? Well, if anybody's been dangling around pregnancy tests, I'm sure you've seen those. Hey, our kiddo, our newest kiddo, the new Garofali is actually due right around APHA. Go figure, the annual meeting, not perpetually. So yeah, the G's will not be at the meeting this year. First time in forever, actually, since our last kid. Anyways, but pregnancy tests are one. COVID tests are one. I'm not going polar here. I'm just saying the immunoassays are one version of this. They're generally referred to as screenings. Whereas the gas chromatography, liquid chromatography, mass spec, that's urine drug testing. That is definitive. That holds up in clinic and court. That is a great manner of having a powerful conversation with our patients. Not always negative, just really helping along the way. Urine drug screening and immunoassays are presumptive. They start a conversation, basically. They're quick, though. They're cheaper, by far, relatively, of course. And, you know, one of the things Emily already covered earlier, too, was the idea of the frequency. You know, we all don't live and work and thrive in utopia. There maybe will be scenarios across the country, situations where it might not be financially feasible to do a urine drug testing or even screening at every single appointment, depending on the frequency and all that. But generally speaking, that is, you know, best practices to just always. But cost comes into play here, too. We're just going relative. Got some dollar signs on here, too. But we'll go a little bit deeper in a moment here into things like false positives, false negatives, cross reactivity. There's a lot of baggage that comes with those cups compared to the tests. And that's where we want to go there. One of the things we'll go over next here is basically just the cutoff levels. So a cutoff level. We're not talking limbs here, thankfully. We're just talking about how much of a substance needs to be in the liquid for the screening or the test to say, hey, that's present. Not one molecule, not one single, you know, nanogram along the way. These are the levels. They're always typically always in nanograms per ml, as we have labeled here, of course. So it brings up the idea there when we say like, oh, urine drug testing is infallible, holds up everywhere. The cutoff levels come into play for that. So that's something just to keep in mind. But usually they're so relatively low that it's really not worth much more further conversation. Now, next up is the consideration overall of urine drug detection times. Wouldn't it be great if every substance was the same time duration that you'd be able to detect it in the liquid? In this case, the urine, the specimen. But that's obviously not the case. And, you know, we as pharmacists, as pharmacy professionals, quite frankly, we know there's a lot of pharmacology to respect. Things come into play, like we see here, perhaps highlighted with with benzos, the short acting, long acting. So, of course, the longer acting, those that have more, the benzodiazepines that have more active metabolites, thus creating a longer acting situation. Those have a longer detection time as well because they're just longer. Lipophilicity comes into play. Here we have it labeled as marijuana, typically talking about THC in that realm, highly lipophilic. So it's going to be deposited throughout our body and our fat, regardless of how much we've got. Hopefully everybody's New Year's resolutions are going strong, right? The longer that someone utilizes marijuana, the longer that it's going to be in their system. Semi easy way of remembering it. But the important thing is just remembering that idea in general that it's going to be longer. Those are things that come into play along the way. But one of the aspects overall is, you know, where do we even begin? Like these was the basics that Emily and I just covered here. But up next, I wanted to make perhaps even a colorful chart. A way to wrap our minds around the idea of different urine drug screening panels. OK, now again, this is CUP. This is unique to generally unique to urine drug screening CUPs, the immunoassays. What we use across our country for things like employment, so on and so forth. The very common ones are typically the five, maybe the seven panel. Now, as you can see here, we're looking at a relatively low amount of things. But the more observationally prevalent across the country and globe for that matter, substances, THC, cocaine, opioids. I know it says opiates, but it's really opioids, folks. Don't get me going. PCP, kind of random as a hallucinogen, quite frankly. And then amphetamines. It's pick in five. There's certainly more. There's hundreds more, of course. But the overall idea is, you know, especially as clinicians, whether somebody is in a specific specialized clinic, whether it's SUD, pain, so on and so forth, or even general practice. Typically, the more included in the panel, the better. And you guessed it. The more included in the panel, the more it costs. Right. But when using these panels, that's that's really going on the micro. Next up, what I really want to cover here is this. When using the CUPs, this is for urine drug screening, the CUPs, the immunoassays. There is a relatively appreciable concern for false positives and negatives. I actually hesitate on saying appreciable because it's real. Hopefully what your eyes can navigate to here is just realizing that, you know, even if you were to pick the moderate presumption here of an average, not to. I don't know how many folks are meant to hear they could do this in your head. But if you're just looking at this, you're seeing maybe except for those outliers, the rather tall antidepressant and meth green bars, 30 ish percent, maybe a little bit more. So we could say one in three. Now, think about that. If using the immunoassay, the screening, the CUP, and it could be wrong in either a false negative or a false positive one out of three times. It's a little play on statistics there. That's not exact, but go with me conversationally. If something's wrong one out of three times, that's not even good for meteorology. And it certainly isn't good for healthcare, right? So it begs that question of, well, how do we go about this? And that's what Emily and I will continue in our conversation here. But going a little bit further on these false positives, because the false negatives are, the idea there would be that the substance is in the person, but not being reported. That's one story. Here, we're looking at false positives where the person is not utilizing, not consuming, not intaking the substance, yet the screening is saying that they did. Do you wanna be that patient? I don't wanna be that patient. This is information that gets a little bit tricky for sharing out there, because then some folks will say, well, why do we share this one? Well, if we don't know as clinicians, then we can't provide the highest level of care possible. So based typically on structure, I am not a med chem guy, but I do like to respect the pharmacology. And part of that is the structures, okay? Depending on when we were all in pharmacy school, it's been less and less these days of concentrating the structures, the chemical structures of things, but they really do matter too. Mentioned it for words earlier. Here, that immunoassay, it's looking for similar structures. And if something has a similar structure, the immunoassay is gonna ding, ding, ding, winner, winner, not a chicken dinner when we're talking false positives, okay? Couple examples here. You got over-the-counter medicines even, like NSAIDs, PPIs even, prescription of pantoprazole. Those along the way could be concerns when it comes to things like, we're seeing here for cannabinoids even, but we're also along the way there in the opioid realm, things like diphenhydramine over-the-counter, quetiapine for methadone. That's one you may have heard recently, but that's something that's, it gets sensationalized where we see it in our criminal justice systems, but it's really throughout society as well. Now, the idea of looking for those structures, that's when it's like the first time in the history of pharmacology that we could somewhat rely on Dr. Google saying it conversationally. If you look at the structures, you can see if there's a similarity, you might be onto something as a false positive. CBD, THC, I'm sure your eyes are going right to the structures here now. You can probably see a lot of similarities there. This is one of those prime culprits for having quite the conversation when it comes to, could there be a false positive? So CBD and THC have very similar two-dimensional flat structures. When they become 3D, it's a little bit different, and our bodies are certainly assessing things in a 3D manner, so there's that. But cannabidiol or CBD should not screen positive for THC. However, a couple of things to consider for our patients, family, friends, and community, quite frankly. There's a high percentage of products that contain other substances. There's been multiple studies now, we're highlighting one here from JANA 2017, that are showing that the CBD extracts had not accurate labels in about a third of the time, give or take. There's been follow-up studies, I believe 2019 and 2020, where some of the more robust ones are starting to see slightly improved results, but not quite there yet. Capitalism is moving the bar, but it's not where it needs to be in the medical realm yet. But those continuation of those studies will help us out along the way as well, too. All right, so that's all in the cannabinoid realm. But let's do our first patient case here. So JP has prescribed oxycodone ER and hydrocodone acetaminophen. The rest of the world knows it as paracetamol, right? After review of his medical records, he's also prescribed cyclobenzaprine and dronabinol for pain management. Got that approved, right? Routine 12-panel UDS was positive for opiates, oxycodone, and TCAs. Are those results as expected, given the patient's current medication regime? Just think about that overall, not really a poll situation. So the answer here, of course, is gonna be false. And you might get a little, you might be wondering on that because as we can see further here, it's not expected because there's not a TCA as we recognize it prescribed and utilized here. But what else is going on? What about those structures there along the way? In this case, that cyclobenzaprine has a structural similarity to TCAs, tricyclic antidepressants. In fact, it's extremely close. Most would say cyclobenzaprine is a TCA under another name with a ring code over him or her, right? But what happens next? It is really where we wanna go next in our thoughts here, too. So next up, we have urine drug screening, again, the CUPs, false negatives. What could contribute to this? Dilute urine, overhydration. We actually see this in multiple schools of pharmacy and various employment situations when people have to go to get their urine drug screening or testing for employment or healthcare practices and whatnot, where folks are just overhydrated. It gets pretty annoying for patients because it's not a contentious situation. It's just they drink too much water probably. And naturally, folks are inclined to say, oh, I have to go for a urine drop. I better drink more. Also, low urine drug concentration. The whole as-needed use for medications with no use prior to screening. If it's not in the body, in the person, it could be in the urine, right, per se. And then also the increased time between the actual administration of a medicine and the screening time itself. And one of the other things we wanna go over here, too, is, again, we're in that realm of what about when things are wrong or unexpected? So next up is the idea here with urine drug screening. Again, the screenings. We're not picking on the immune assay cups. We're just saying these are things we gotta keep in mind when they're utilized. But workarounds. There's home remedies. You could go online and find human urine recipes. I kid you not. I really hope that my employer never checks my search history. It's not because I'm up to anything, any shenanigans or anything like that. But it's just the realms we work in. But there's others we have listed here, too. The whole Golden Seal with THC myth that's out there. Cranberry juice, the pH work and things here. Synthetic urine. Urine can be purchased. You can buy anything you want, anytime, anywhere. It's called online, right? And you don't necessarily need the dark net, either. There's even, there's different companies out there. One ends in Nader. I believe it begins with Wiz, right? Check that one out if you'd like. Not at work, though. You can get some pretty interesting pictures that come up. People could just dilute. Emily talked earlier about the idea of water being in the toilet. If going to that level of watching and trusting but verifying. Remember the top of the toilet, too. If you're just putting blue or red or pink or whatever in the actual toilet, don't forget about the basin up top, too. Substitution, use someone else's urine. We've seen things even, hand warmers, right? Most of our country is cold right now. And if you're not, you're gonna be tomorrow because there's a polar vortex coming, right? To at least East Coast-ish, Northeast. They got hand warmers. Well, you could duct tape those poppies to your leg and have a bag of urine there and it's gonna be warm then. All of this leads in that realm of negativity, but it's not meant for that. It's just knowing things so that we could have people allow us to help them along the way. All right, so next up here, the idea, see, we went over all these concerns when it comes to urine drug screenings, the human assay cups. Next up is the idea that, well, if that just kind of hits the fan, what do you do? Or perhaps initially even, if possible, when possible, utilizing urine drug testing, the big fancy machines, gas spec, liquid chromatography, mass spec along the way. The urine drug testings are the idea that you're gonna avoid all these unexpected concerns as much as humanly possible. I always say holding up in clinic and court. So the answer is usually to transgress to utilizing urine drug testing, if not utilizing it already. So that, I hand it off to Emily to kind of take us down the final pathway here of like, okay, well, then what? What do we do once we're in that realm of urine drug testing along the way? Okay. Okay. So when we think about urine drug testing and negative results, as Mark started to talk about, what are some possible causes that you may see? So patient may have never taken the medication. Patient may have decreased oral absorption of the medication or decreased urinary excretion of the metabolites. Medication was taken too many hours before the test, or worst case, medication was stolen, sold, or otherwise illegally distributed. We don't know. And so as Mark said, when we talk about a urine drug screen, it's more of a presumptive, let's have a conversation with the patient. Hey, these results aren't what we're expecting. But when we think about a urine drug test, if we see a negative result, that is the truth, right? That is definitive. The urine drug tests don't lie. There's no false positives or false negatives with urine drug testing. So if a patient tested, their test showed a negative result for something we would have expected to be positive, then that's a conversation we're gonna have to have with the patient. And we're gonna talk about how to approach some of those conversations in a few slides. But before we get there, I wanna talk about what might you expect on a urine drug test as well when it does come to metabolites. So the diagram here might look a little overwhelming, but when it comes to opiate or opioid and benzodiazepine metabolism, you may see positive results for substances on a urine drug test that a patient is not taking, but are commercially available. So for example, if a patient is prescribed codeine, Tylenol with codeine, a minor pathway of codeine's metabolism is to hydrocodone. And hydrocodone is then metabolized into hydromorphone. So if a patient's prescribed codeine, you may see a positive result for hydrocodone or hydromorphone. And because both of those medications are commercially available, at first we may say, wait a minute, that doesn't make sense. Our patient is not prescribed that. They must be getting that illicitly. When in reality, that's not necessarily true. Same thing with morphine. Morphine's metabolized to hydromorphone. If we think about the oxycodones and oxymorphones, oxycodone is metabolized to oxymorphone, which is another commercially available product. So when we're looking at a urine drug test, we do need to be cognizant of what is the metabolic pathway because we don't wanna walk into a patient room and say, you're using oxymorphone. I'm sorry, I can't prescribe for you anymore. And they're like, what are you talking about? I'm not using anything that I'm not prescribed. And so these metabolites are what you're gonna wanna be aware of because if you do send a urine sample for urine drug testing, you are gonna get back hopefully positives for these medications along with cutoffs. And think about, well, what if a patient's prescribed oxycodone and their urine sample was only positive for oxycodone? Why are there no metabolites present? And there can be, maybe the patient popped the pill right before the urine drug screen, or maybe the pill was dissolved in the urine sample in an effort to make it look positive. And Mark and I are not trying to teach you all of the ways to get around a urine drug screen or how patients may get around a urine drug screen, but these are things we wanna think about when we're monitoring for abuse or diversion. And that's where pill counts can come into play too. If we are suspicious about why there's no metabolites present, we could be performing pill counts to make sure that they match with what was prescribed and when it was dispensed according to the Prescription Drug Monitoring Program. So this might be a good slide to keep a reference of, especially if a patient is using heroin, you may see codeine, you may see morphine, you may see hydromorphone, all positive, but those could be potential pathways from heroin. So if we think about the breakdown, the metabolism of some of these agents, many of these drugs are hepatically metabolized through SIP enzymes. Some are metabolized through glucuronidation that don't lead to an active metabolite. But the reason I show you this slide is that genetic polymorphisms for SIPs can potentially account for a wide variety of serum levels in a variety of different patients. That doesn't mean we need to perform genetic testing on all of our patients, but if a patient has liver dysfunction, then maybe we see higher amounts of this parent drug versus the metabolite or things of that nature, especially with the 2D6 polymorphisms, you may see some differences in metabolism. And so this is just something that you wanna keep in mind. If we think about benzodiazepines, benzodiazepines also are metabolized to other commercially available products. So diazepam metabolized to temazepam, which is commercially available. Oxazepam, commercially available. You can see that oxazepam would be positive if a patient was to use chlordiazepoxide or chlorazepate or diazepam or temazepam. You're gonna see oxazepam, which is a commercially available product. So being aware of how drugs are metabolized, the chemical structures of drugs is certainly going to help you when you're looking at urine drug screening and urine drug testing in patients who are prescribed these controlled substances. Benzodiazepine metabolism, lorazepam, oxazepam, and temazepam are all metabolized through glucuronidation. So they do not lead to an active metabolite. And so temazepam, well, excuse me, temazepam is metabolized through glucuronidation to oxazepam. But what I really wanted to point out is the drugs that are metabolized by CYP enzymes. So primarily CYP3A4, we see diazepam, triazolam, and alprazolam. And so if you are, you know, if a patient has hepatic dysfunction, then these may be benzodiazepines we want to avoid, especially because diazepam has an active metabolite and that potentially could lead to worsened adverse effects and worsened consequences. So how do we have conversations with patients? So as Mark mentioned, urine drug screens are conversation starters, meaning when we talk to a patient, we can say, we analyzed your urine sample that you provided today, and it showed a positive result for X, Y, Z substance. Now, we're only prescribing you this particular substance. So have you used anything else recently, whether that be from a friend or an old medication that you maybe had had? We don't ever accuse the patient because there is the risk of false positives. Same thing if we prescribed a patient an opioid for as needed use, and it shows back negative, and we would have expected a positive, we ask the patient, have you taken the medication? If they say yes, when was the last dose? In trying to get the patient to give some more information, but with only a urine drug screen, we would never walk into a patient's room or talk to a patient and say, well, you tested positive for diazepam, temazepam, and oxazepam, and I'm not prescribing those opioids or those benzodiazepines, what did you take? Where did you get them? Or, oh, you didn't show positive for this, you must be selling it. So those are not the conversations we have, and those conversations can be very stigmatizing to the patients. So conversation starters being, let's have a conversation because I didn't expect these results, but there are false positives and false negatives. And sometimes patients do get upset about what their urine drug screen shows because they have been taking their medication religiously, exactly as it's prescribed on the bottle, and we say, okay, well, there is the possibility of false positives or false negatives, and so we're gonna send it to the lab, and that'll give us a better idea of what may be going on. So discussing the results with the patient is certainly going to be important, whether that's a urine drug screen or a urine drug test. When the urine drug test results come back, because those are definitive, it does become a different conversation. So I wanna move into our next patient case. So we have patient AZ, who is prescribed morphine extended release and dugloxetine, so an SNRI that's commonly used for neuropathic pain, anxiety, depression. So the routine 12-panel urine drug screen was negative for all substances. Okay, well, that's not what I would have expected because I would at least have wanted to see positive morphine. Okay, so we're gonna send that to the laboratory for confirmatory urine drug testing, and this is where we'd have a conversation with the patient that says, hi, your urine drug screen was negative for morphine. Are you still taking this medication? If the patient says yes, I may say, how often are you taking it? When was your last dose? What other medications or supplements might you be taking? Because it could be a false negative. So we send our urine sample to the lab for urine drug testing, confirmatory results, and we see a positive result for morphine, marijuana, and cocaine. Okay, so these results are not expected. The morphine, yes, but marijuana and cocaine, no. At least in our background of our patient case, we don't see that the patient is using those substances. So then we have a conversation with our patient saying, okay, we got the results back from your urine drug test, and you showed a positive result for morphine, marijuana, and cocaine. Are you using marijuana and cocaine, or have you used them in the past few weeks? And we see what the patient says. If they say no, I swear I haven't used them, I say, okay, well, these results are definitive. So there's no possibility of a false positive here. So at some point, you have to have ingested these substances. And I can help you if you have a conversation with me about where these may have come from. Marijuana could be found possibly in a CBD gummy, and kind of explaining where a patient may have seen these substances. In New York State, where I am practicing, marijuana is recreationally legal. So I'm not as concerned if a patient is using marijuana, especially because it does provide pain benefit, but it's still a conversation that we'd wanna have with our patient. And then where did the cocaine come from? And so if the patient still swears, still swears that they didn't use anything, then we say, okay, well, the problem is, is that we can't safely continue these other medications that we're prescribing you, if these other substances are present in your urine. So when we would repeat the urine drug screen, so when would we redo the urine drug monitoring? In this case, the patient's risk has increased because they are using illicit substances. And so in that case, maybe we have the patient come back in two weeks and we perform another urine drug screen, or maybe at this next appointment, when we're reviewing the urine drug testing, we obtain another urine sample. And depending on how the conversation goes, depends on whether or not we may need to refer the patient to a substance use disorder specialist or a different program. So if there is confirmed diversion, or if there is confirmed use of illicit substances, we wanna go back to our provider agreement or contract. The patient signed this agreement. And in that agreement, there usually are terms of if this is, if there's a consequence for, what is the consequence if the patient violates the contract? Are they given three strikes and then they're out? What happens? And that should be laid out because the patient is then signing that document. We can continue treatment with non-controlled substance therapy. So that doesn't mean that we should just kick the patient out the door. We can still provide pain management services. Maybe this patient needs to be referred to an SUD specialist if we were seeing illicit opioids being used. If there is a concern for the safety of the patient, we may want to consider having law enforcement involved, but that could also send the wrong message to the patient. So we wanna be very sure that there is a concern for patient safety. And we wanna respect all of those patients that are involved in the patient case. We want to respect our patient. We want to work with our patient. And we don't want to abandon the patient. We could go on a whole nother presentation on harm reduction. But if we could just go back to the previous slide, I'm sorry. Thank you. So, but we do also need to make sure that we are following both federal and state laws and providing an appropriate level of patient care. So as I mentioned, we don't want to abandon our patients. And that is directly listed in the CDC guidelines. So ways to think about if there's going to be concerns with prescribing, and really we don't know how a patient is going to progress throughout treatment. So throughout any patient, we should be documenting our patient encounters thoroughly. We should be documenting with quotes if possible, whether or not the patient admitted to using a substance or still continues to deny using a substance despite confirmatory drug testing. We may need to involve other interprofessional individuals. So other disciplines. We could consider non-pharmacologic treatment strategies. We can consider possible, if we want to think of a social worker or a therapist to kind of talk about various coping strategies if the patient's using substances for, if they're self-treating in a way. But we should really stress the importance of continued patient care. So we do not want to abandon our patient. We want to continue to work with them. And in that way, we can continue non-controlled substances. And we, but we need to have policies in place on how we want to work with our patients and what happens if we do see a urine drug test that is not expected. And that can also consider submitting referrals to other professionals as appropriate. So as a summary for everything that we kind of covered, urine drug monitoring involves screenings and testings. Screening, so your point of care urine drug screen with a sample cup is presumptive. It can help us identify what may be going on, but there is the possibility for false positives and false negatives. Now, in our first patient case, we saw that the, you know, cyclobenzaprine may have been a false positive for TCAs. That doesn't mean we have to run and do a definitive urine drug test because we would have expected that cyclobenzaprine maybe caused a false positive. So in those regards, there may be some concern or maybe lack, we don't need to be as concerned because we did understand that there is that possible cross reactivity. If we're worried about a possible false positive, you can always look at the chemical structure as Mark had mentioned to look for similarities. There is no concern with false positives or negatives with the urine drug test, it is definitive. Keeping in mind that many opioids and benzodiazepines are metabolized into active metabolites that are commercially available products, knowing the metabolic pathways is important so we're not accusing or assuming our patient is using other substances when it's simply an active metabolite. And there's no such thing as too frequent monitoring. So, you know, monitoring frequency can be determined based on a patient's risk, but we can also perform random urine drug monitoring if we are concerned about something or we may just have a random rotating list of every patient in our office who we call and ask them to come back. So with that, I'm going to turn it back over to Anne and we're gonna answer some of your questions. Great, Emily and Mark, thank you so much for your comprehensive overview of this important topic. We have just a few minutes and we have questions in the question box. So we'll see how many of these we can run through quickly. And then if your question is not being addressed, Anthony, our behind the scenes staff person is going to put into the chat an email address where you could send your question and Emily and Mark have graciously agreed to answer questions that come in that way. So the first question is, does age matter when discussing results of UDS or UDT? Do minors require an adult present? Emily, I don't know if you wanna take that one. Sorry, I had muted myself. It depends on what you're treating the patient for, whether or not the patient wants their guardian there. You don't need to have a parent there depending on the age. I mean, if the child is an adolescent, they're in their teens and they want to be discreet, we can have conversations without a parent present. If it does come down to patient safety, then we may want to have a guardian involved, but this is gonna be dependent upon how you feel with the patient and how the patient wants you to treat them because they do come first. There are instances where children and adolescents can make appointments and not list their parents on HIPAA documents. And so that would be an instance where we would just have a conversation with the patient, but we can tell them that we have the opportunity to provide support if needed. Thank you. Mark, I'm gonna direct this next one and I'm gonna combine two questions. One is, is there a test for pre-gabalin or gabapentin? And then we got a different question around detecting kratom. And I probably pronounced that wrong because I'm bad at that sometimes. No, you went with the colloquial tropical kratom. Kratom will be, I guess, what we do here in the Americas, but as far as pronunciations. So the beauty of any of this urinary monitoring is that with a robust wallet, whether digital or old school papyrus, you could have anything. So there are add-ons for the screenings. If you remember back to that chart that we attempted with the different panels, those are a grouping. That's not a la carte, but there are a la carte options to add on things like gabapentinoids, kratom, so on and so forth along the way. It gets a little bit more robust perhaps for what's on the menu for a la carte for urine drug testing, but it's all out there too. And it brings up a really good point because those are communications that are gonna be happening between your practice, the audience, not you, Emily or Ann, unless it is, but your practice and whoever you have contracted with to do these screenings and tests. Those are very important relationships. Anytime any business or organization makes a contract with any type of service, it's all about the service. So setting things up where, like I know in our, I call it Utopia Clinic, we don't really have to look things up. If there's something off kilter based on parameters that are preset, you get a message so that clinicians can just carry on with their day with the presumption that's concrete on everything was as expected because I didn't get a message. And when there is something off here and there, the pharmacologist wants to look at those structures like I mentioned earlier, but you can reach out to the reps too. That's a really important thing along the way for whoever in the world you're contracted with for that. Great, and I see we just have a few minutes left. So I think we're gonna move to the polling questions. We did have several other questions, but we can put them into the queue and have them answered afterwards. So Mark and Emily, sincere thanks again for being with us today and covering this important topic. And I know we've got people sticking around for CE. So if we can move to the polling questions. Okay, so if you can all answer, which of the following medications can possibly produce a false positive urine drug screening for methadone? We'll give you just a couple of seconds. Oh, it's looking good. All right, I'm gonna close the poll and the clear majority of you got the correct answer, which is answer C. If we can move on to the next question. Which of the following meth, sorry, a patient using morphine may also show a positive result for what on a confirmatory urine drug test? Excellent, we're seeing good response. The correct answer to this question is B, hydromorphone. And then moving on to the next question. Urine drug monitoring should be performed for low-risk patients, a minimum of how often? Oh, you all did very well on this. The correct answer is D, 12 months. Okay, if we can move on to the next slide. I'd like to take just a minute and mention the PCSS mentoring program. This may be of interest to a lot of you. It's designed to offer mentoring assistance to those in need of one-on-one interactions with an expert colleague to address clinical questions. You have the option of requesting a mentor from their mentor directory, or they're happy to pair you with one. And to find out more information, please visit the link that's at the bottom of this slide. Next slide. PCSS also offers a discussion forum that's comprised of their mentors and other experts who can help provide prompt responses to clinical cases and questions. They also have a mentor on call each month, and the person is available to address submitted questions through the discussion forum. You can create a new login account by clicking the image across the registration page. Next slide. These are the organizations. APHA is a proud partner with PCSS, but these are the organizations of lead partner orgs that are part of the PCSS project. Next slide. And then you can reference this slide for contact information and their Facebook and Twitter account to find out more about PCSS resources and educational offerings, which are very extensive.

webinar

urine drug screen

interpretation

American Pharmacists Association

Dr. Emily Lapine

Dr. Mark Garofali

point-of-care tests

false positives

false negatives

urine drug monitoring