New York State Medical Treatment Guidelines for Urine Drug Testing (UDT) for Monitoring Opioid Therapy in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for conducting urine drug testing (UDT) to monitor opioid therapy for non-acute pain. These directives aim to assist healthcare professionals in employing UDT as a means of monitoring opioid therapy within the scope of comprehensive care.

Healthcare professionals with expertise in utilizing UDT for monitoring opioid therapy can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most appropriate methods for monitoring opioid use in their patients.

It is important to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The use of UDT for monitoring opioid therapy should involve collaboration between the healthcare provider and the patient, considering individual factors such as opioid dosing, treatment adherence, and potential misuse or diversion of opioids.

Urine Drug Testing (UDT) for Monitoring Opioid Therapy

  • The purpose of urine drug testing (UDT) is to detect any irregular behavior, undisclosed drug usage, or abuse and to confirm compliance with prescribed treatment. When utilized correctly, UDT can enhance a physician’s ability to manage opioid therapy safely and effectively. Random UDT is recommended as a means to monitor adherence to prescribed substances and to identify any undisclosed substance use that may influence treatment decisions.
  • It’s important to note that UDT results alone do not dictate a specific course of action. Instead, they should be interpreted within the context of each patient’s unique clinical situation. The test results should be considered alongside other clinical information, such as observations, addiction screening outcomes, pill counts, prescription drug monitoring reports, and input from family members, other healthcare providers, case managers, and pharmacy staff. Physicians should consider various potential explanations for abnormal UDT results, including drug abuse, self-medication for poorly managed pain, psychosocial factors, or diversion.
  • UDT is an essential aspect of chronic opioid management, forming part of both the initial assessment and ongoing evaluation of opioid therapy.


Baseline UDT:

  • Baseline UDT should be conducted for all patients who are transitioning to opioid therapy or are being considered for ongoing opioid treatment. This baseline test helps establish a starting point for monitoring and evaluating opioid therapy.


Prior to Testing:

  • Before conducting the urine drug test (UDT), the physician should explain to the patient the purpose of the test, the expectation of future unscheduled testing to verify adherence with the Patient Understanding for Opioid Treatment Form, and the potential outcomes of unexpected results.
  • Random UDTs should be scheduled based on the patient’s risk category, as indicated.
  • If the frequency of UDTs exceeds the recommendations, the ordering provider must provide a clear medical justification for the increased frequency.
  • The specific drugs to be tested for in the UDT may be determined on a case-by-case basis at the discretion of the ordering provider. However, overly extensive test panels may prompt the provider to explain the medical reasoning behind such a choice.
  • If a patient exhibits aberrant behavior, such as lost prescriptions or unauthorized dose escalation, a UDT should be conducted at that visit.


Confidentiality and Reporting UDT Results:

  • Patients have the right to refuse a urine drug test, but refusal may result in the provider withholding opioid prescriptions. The decision to prescribe opioid medication remains with the provider, and refusal to undergo UDT may influence this decision.
  • UDT results should not be disclosed to the carrier, employer, or the Board. However, the treating physician must document the patient’s adherence to or noncompliance with the Patient Understanding for Opioid Treatment Form in the medical record.
  • The frequency of UDT should be determined by the treating provider’s clinical judgment, adhering to the guidelines provided.
  • Employers cannot misuse test results to discriminate against or penalize workers.
  • The guidelines outlined in the New York Non-Acute Pain Medical Treatment Guidelines do not apply to acute care scenarios.


Methods of Urine Drug Testing:

    • Two main types of UDT are available: immunoassay drug testing and high-performance chromatography/mass spectrometry (confirmatory drug test).
      • Immunoassay drug testing, the most common method, can be performed in a lab or office and provides rapid results but may react with other drugs. It does not measure the quantity of drugs used.
      • Confirmatory drug testing, recommended for specific drug verification, utilizes gas chromatography/mass spectrometry or liquid chromatography/tandem mass spectrometry for precise identification.


Interpreting Results:

  • Understanding UDT results can be complex, especially when the parent drug can be metabolized into other commonly prescribed medications.
  • If an immunoassay result is unexpected, a confirmatory test using GC/MS or LC/MS should be conducted.

Negative Results:

  • If confirmatory testing and clinical judgment confirm a red flag and the result is negative for the prescribed opioid(s), the patient should return for a pill count and repeat urine test. If the urine remains negative, the patient should revisit the office in two days for evaluation of withdrawal symptoms. If no withdrawal symptoms are evident, consider discontinuing the opioid(s) due to suspected diversion.

Positive Results:

  • If confirmatory testing and clinical judgment confirm a red flag and the result is positive for a non-prescribed scheduled drug or other drugs without a valid medical explanation, the provider must assess the medical significance of this finding. Depending on the assessment, actions such as reinforcing the Patient Understanding for Opioid Treatment, tapering or discontinuing opioid prescriptions, increasing monitoring, or referring to specialty care should be considered, especially in the absence of a valid explanation.
  • In such cases, certain actions should be taken: categorizing the injured worker as “high risk” with corresponding testing frequency adjustments, implementing random pill counts at least quarterly, and initiating medication tapering immediately upon a second positive urine drug test without a valid explanation.
  • Alternatively, a three to five-day inpatient medically assisted withdrawal (detox) program may be considered, supervised by a physician with appropriate training or board certification in addiction medicine, possibly coupled with long-term support programs such as Alcoholics Anonymous or Narcotics Anonymous.
  • Noteworthy behaviors that should trigger the patient’s categorization as “high risk” include selling prescription drugs, forging prescriptions, unsanctioned use or dose escalation of opioid medication, obtaining opioids from multiple providers, frequent loss of prescriptions, and aggressive demand for opioid medication beyond reasonable clinical needs.
  • For assistance in interpreting drug testing results, consult your local laboratory director.


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