How Urinalysis Can Filter Out Illegitimate Requests For Pain Meds

It is yellow in color, usually clear, has a specific gravity ranging from 1.001 to 1.035 and a pH of 4.6 to 8.0. It doesn’t look (or smell) like anything special (most of the time), but it has the power to give us great insight. This yellow fluid cannot lie. Granted, its vessel can damn sure play some games, even buying fake fluid on the Internet in an attempt to mask other deceptions. However, this yellow fluid is what it is and it is what they have ingested, smoked, snorted and ultimately metabolized. On the flip side, it is not what they haven’t ingested, which can provide its own kind of proof.

“He’s talking about urine, isn’t he?” the little voice in your head with the Texas twang bellowed. Don’t worry about the self talk. We all have it and it can remind even guys like Sherlock Holmes to go back to the crime scene.

Let’s talk about urine. It can tell you a lot if you want to know. Frankly, I never listened to it that much and especially didn’t want to look at it. The only times I paid attention to it was when it had a color, consistency or murkiness that was alarming. But regular old pee? When was the last time you cared much about it (well, other people’s that is)? (I’ll tell you the last time you paid any attention to urine was when you drank three cups of coffee on your way to clinic and got stuck in traffic, then your own might be very much on your mind.)

“Probably never,” Tex whispers in your ear.

So how did this expedition down the yellow river start for me? A few months back, a very lovely, articulate lady paid me the good fortune to visit my office. Normally, I would have shunned her and her demo cups faster than Usain Bolt sprinted the 100-meter dash, but I saw those little colored coated windows on the cup. She called it a "quick cup." I was curious. I mean, it looked pretty fancy. How many of you have your patients give you a specimen, just a little tinkle now and then? Not many, I would guess because you are, at least in so much as practice routines are concerned, probably similar to me.

Urine testing is nothing new to medicine and in fact the “piss profits” made a handsome living off analysis of the amber fluid in the Middle Ages.1 Dudes like Galen smelled it, looked at it and disgustingly as it may seem, tasted it way back in the 3rd century AD. Diabetes mellitus owes its name to it as in 1674, Dr. Thomas Willis, a major league piss profit, discussed how the urine of patients with diabetes had a taste that was “honey sweet” (mellitus). The disease and its sequelae that we battle so often today was known as Willis’s disease.

“So yer tellin’ me that doctors used to have to taste that stuff?” Tex whimpers.

"Yeah, Tex. They tasted it, smelled it and sometimes predicted the donor's future by observing it." They even had “urine wheels” to compare samples to.

How Urine Testing Recently Worked In My Practice

Now fast forward from 150 AD and Galen’s time to 2013 and listen to my real clinic story on how valuable urine testing can be for you.

About four months ago, I performed a very minimal surgery on a nursing student (name is changed to protect the not innocent), and she came back to the clinic on each post-op visit stating that she still had pain and needed more pain meds. The pain was out of proportion to the surgery. There was no edema nor erythema, and when examining the patient, I could not really find a painful area to palpation with her distracted.

"But it really hurts," she would say. "What would you do?"

If the patient tells you she has pain and looks like a "legitimate" patient, you give her more opiates. This patient was well groomed, well dressed and well mannered. Not to mention it again but she was a nursing student.

"I have to take three of those Tramadols at the same time to get any relief.”

Something just didn’t compute here. Tex started chirping in my ear, “Let’s get some of her tinkle in that quick cup, cowboy."

"Good idea, Tex." I forgot to mention that the “nursing student” patient always had her mother with her. Like any other courageous provider, feeling that he was being duped, I sent my medical assistant into the room to tell the patient that we needed a urine specimen.

I was not in the room but the reaction II saw while the patient was walking down the hall said it all. She was profusely sweating, and had big googly white sclera, like high beams on a dark two-lane highway at midnight. Later, my medical assistant told me the patient asked if she could have some water. Then after giving her the water, the patient asked if she could take it with her to the bathroom. Just a hint, Watson. Of course, my medical assistant quickly smelled a rodent and said no emphatically.

A few minutes later, my staff summoned me to come to the laboratory. Aha. Holding the cup up like a prized trophy, my able medical assistant, not named Watson, smiled devilishly. "THC and no Tramadol.”

Tex started right up and without any respect. "Hey, Dope, you’ve been duped."

It is truly astonishing how quickly the post-op patient improves after you tell her that: a) she is smoking weed and b) there is none of the drug in her urine that you prescribed to her. Now Sherlock would tell Watson that she was likely selling her "legit" drugs that I prescribed her to buy pot with the money she received, but that is what speculation and interrogation are all about.

While it may be uncomfortable to ask patients for a urine specimen, today’s medical climate really requires it for those patients who receive narcotics and keep needing more, and have pain outside the expected amount.

Look, you may be thinking, "But, I know my patients. No way these good folks are doing that!"

Really? There is a Website where you can go and look up the street value of any prescription drug. The values … well, let’s just say it would be a great way to cover your deductible (I am not advocating that. Just want to make that clear). You might be shocked to see the numbers on “party drug” usage and who is using it.

When it comes down to it, wouldn’t you rather suffer a little to ask that patient to give you a sample rather than risk your medical license and/or your patient’s life? As for me, I embrace the pee.

Reference

1. Available at http://thechirurgeonsapprentice.com/2013/12/06/piss-prophets-the-wheel-o... .



Robert Smithsays: January 21, 2014 at 3:27 pm

I read Dr. Barrett's blog with great interest. Because of my current status, I was trained and certified by the DOT to obtain urine for testing for illicit drugs (UDT). It was an intense training course.

The podiatric physician must understand the basic metabolism of commonly prescribed drugs, especially opioids, so they will be able to explain a UDT result that is positive for the prescribed medication and/or its metabolite(s).

UDT in clinical practice must be used to improve patient care. Unfortunately, these test results may come back unexpectedly negative for a prescribed drug or positive for an unprescribed one. The first step in interpreting these results is to contact the lab to ensure that no clerical errors have been made. If unexpected results are confirmed, there must be a process in place that should include discussing the unexpected result with the patient.

Further, and most importantly for both the podiatric physician and the patient, the cost of the UDT must be researched. My father who suffers form chronic pain secondary to radiation burns has been receiving Oxycontin for a number of years from pain management. His monthly contract calls for a UDT which is no longer paid by TRicare for life. In order to receive his monthly prescription, he is now responsible for paying for his UDT that has ranged from 37 dollars to most recently 61 dollars.

Very nice blog. I have supported UDT for many years. Thank you for an on spot blog.

Dr. Bob Smith

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