VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
Appendix B: Urine Drug Testing
A. Benefits of Urine Drug Testing
Substance misuse in patients on LOT is more than 30% in some series.[107] The inaccuracies inherent to
patient self-report coupled with the evident mortality and morbidity to the treated patients, their families,
and others require additional methods to ascertain patient and public safety. UDT and confirmatory
testing is an additional method of examining for patient substance misuse and adherence to the
prescribed regimen as well as the development of trust within the provider-family-patient relationship. It is
critical that the UDT and confirmatory testing be done in a timely, confidential, accurate, and easily
available manner to assure the prescribers, patients, and public that safety, fairness, and trust are being
addressed.
Within the VA, verbal informed consent is required prior to UDT. While a patient can decline to consent to
UDT, a provider can factor that declination into their thinking about whether it is safe to continue with OT
for that patient which is ultimately required if LOT is to be instituted/continued. For more information, see
the VA National Center for Ethics in Health Care website (http://www.ethics.va.gov/).
B. Types of Urine Drug Testing
There are three main types of UDT currently being utilized in clinical settings: immunoassay, GCMS
confirmatory testing, and liquid chromatography-mass spectrometry (LCMS) confirmatory testing.
Immunoassay screening is inexpensive, fast and widely available. However, there are a number of
drawbacks for using this test alone. There is a higher potential for false positives and negatives as well as
lack of specificity of the actual opiate or benzodiazepine being tested. GCMS is highly sensitive and
specific; however, it is expensive and time consuming. LCMS is less expensive than GCMS but more
expensive than immunoassay. It can give a confirmation for a large number of medications, substances
and drugs at one time and may be helpful in many patients at initiation of OT, periodically during OT, and
following cessation of OT if SUD is a possibility. See Table B-1 through Table B-4 and Figure B-1 for more
information.
Table B-1. Urine Toxicology Specimen Validity and Normal Characteristics of a Urine Sample
[189-191]
Urine Toxicology Specimen Validity
Normal Characteristics of a Urine Sample
• Urine samples that are adulterated, substituted, or Temperature within 4 minutes of voiding: 90-100⁰F
diluted may avoid detection of drug use
pH: 4.5-8.0
• Urine collected in the early morning is most
concentrated and most reliable
Creatinine: >20 mg/dL
• Excessive water intake and diuretic use can lead to
Specific gravity: >1.003
diluted urine samples (creatinine