This week, I’ve been thinking a lot of a story I read about a month ago, in which several toxicology labs reported “evidence of non-compliance” in more than half of all urine drug screens performed in a six-month period.
“Non-compliance” can mean several things, and the most interesting part of the article for me was when the original 52% statistic got broken down into its component parts. You might have noticed that of the three categories of non-compliance, the smallest (12%) was the presence of illegal drugs in the urine. The next-smallest by a tiny amount (13%) was the absence of prescribed drugs in the patient’s urine — in the context of addictive medications, this can mean that the medications are being diverted and sold onto the street. However, the largest category of non-compliance, more than double either of the other categories (27%), was “presence of prescription medications not prescribed” to that patient.
This is put forward as evidence of a prescription drug abuse epidemic in our country today, which of course it is. It also, I think, brings up an interesting point about urine drug screens, which is that they are consistently misunderstood and, therefore, probably misapplied. Urine drug screens are perceived as mostly a way to detect heroin, cocaine, and other illegal drugs — that 12% category. They are also perceived as means of exclusion, which they may well be in situations like the workplace, where a positive screen can be grounds for dismissal. There are other situations, though, where a urine drug screen is not so much a test to pass or fail as it is a useful diagnostic tool. Before I started working in addiction, I myself didn’t realize that urine drug screens are used to confirm that a patient is taking what they were prescribed, and that in those cases a negative screen can be cause for concern. And, of course, just because a negative screen for a prescribed medication can mean that the drug is being diverted, that isn’t what it always means. It can indicate that the patient stopped taking the medication because they had a bad reaction, or couldn’t afford to pay for the drug, or are on too low of a dose and doubled up on their meds until they ran out.
In my practice, we use urine drug screens primarily for detecting drugs that we don’t want the patient to be taking; this includes illegal drugs as well as legal prescription drugs, including benzodiazepines (Xanax, Restoril). Patients are often shocked to hear that these medications, which they think of as benign or necessary, are something we screen for and strongly discourage.
This ties back into a few of the topics I discuss here on a regular basis. For instance, this hits right at the heart of the tangled question of blame and personal responsibility. Clearly, patients are not doing what their doctors are recommending, even when the doctors are writing out the prescriptions they want taken; so who is responsible for the patient’s condition when they go off their meds, or overdose? It also speaks to the need for greater communication between physicians, and greater integration of care — are the labs informing physicians, not just of their individual patient results, but of the larger framework of drug use in the U.S.? Are physicians in different specialties aware of the different meanings of “non-complicance”? What is our plan, as a field, to deal with this crisis? Even with strict legislation, we can’t force our patients to comply with treatment plans. The screens themselves are meant to act as a deterrent — if patients know they might be screened, they are theoretically more likely to comply — but should we use some other deterrent if the screens don’t seem to be working? If so, what should it be?
I don’t know the answers to these questions. If you have ideas, share them with us in comments. As always, I look forward to hearing from you.