In these cases, the urine will test positive for the drug—often at a high concentration—but not for its metabolite. Such results should raise suspicion of medication nonadherence. Table 5 lists possible unexpected results from urine drug tests and potential causes. Interferes with immunoassay; may cause degradation of analyte for gas chromatography. Dilution to below cutoff level; decreases immunoassay sensitivity to amphetamines and THC. Information from references 15 and Nonmedical use of prescription medication; false-positive result due to cross-reactivity.
True negatives: patient has not taken medication in the detection window; rapid metabolizer False negatives: urine concentrations below cutoff levels; contaminant present that interferes with test. Ingestion of poppy seeds is sometimes claimed as a reason for an unexpected positive opioid test result.
To study this claim, researchers recruited 15 volunteers to consume a poppy seed roll and raw poppy seeds before undergoing urine and oral fluid drug testing.
Therefore, casual ingestion of a poppy seed—containing food will not cause a positive test result. Similarly, passive inhalation of marijuana smoke has been claimed as a cause for a positive tetrahydrocannabinol THC test result.
Studies have shown that although casual passive inhalation of marijuana smoke does cause elimination of THC in urine samples, the amount excreted is far below the federal and commercial cutoffs for testing and should not cause a positive test. As more persons are required to undergo urine drug testing for monitoring long-term opioid therapy, the cost of testing and coverage by third-party payers are considerations that should be taken into account.
Some insurers limit the number of tests they will cover in a year, and others do not pay for urine drug testing at all. The out-of-pocket cost for urine drug testing varies greatly depending on geographic region and the laboratory used. This article updates a previous article on this topic by Standridge, et al. Data Sources: PubMed was the primary data source used.
Multiple searches were conducted using the terms urine drug tests, urine drug screen, pharmacokinetics, metabolism plus the individual drug names, urine drug screen adulterants, and urine drug screen interpretation.
Preventive Services Task Force were also searched. Search dates: September , and January and April Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Reprints are not available from the author. The association between receipt of guideline-concordant long-term opioid therapy and all-cause mortality. J Gen Intern Med. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids?
Pain Physician. Predictive value of positive drug screening results in an urban outpatient population. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Inter-agency guideline on prescribing opioids for pain. Urine drug screening: a valuable office procedure. Am Fam Physician. Urine drug testing: current recommendations and best practices.
Clinical drug testing in primary care. Technical assistance publication Drug and Alcohol Services South Australia. Urine drug screening: its use in determining patient progress. November Mahajan G. Role of urine drug testing in the current opioid epidemic. Anesth Analg. Windows of detection of zolpidem in urine and hair: application to two drug facilitated sexual assaults.
Forensic Sci Int. Adulterants in urine drug testing. Adv Clin Chem. Pathology consultation on urine compliance testing and drug abuse screening. Am J Clin Pathol. Designer drugs assessment and management. Addict Sci Clin Pract. Stimulant and designer drug use: primary care management. Urinary excretion study following consumption of various poppy seed products and investigation of the new potential street heroin marker ATM4G.
Drug Test Anal. The poppy seed defense: a novel solution. Performance evaluation of three on-site adulterant detection devices for urine specimens. Concentrations of morphine and codeine in paired oral fluid and urine specimens following ingestion of a poppy seed roll and raw poppy seeds. Non-smoker exposure to secondhand cannabis smoke. Urine screening and confirmation results.
Healthcare Bluebook. Accessed October 3, Centers for Medicare and Medicaid Services. Clinical laboratory fee schedule. Accessed April 24, This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Next: Effective Advocacy for Patients and Communities. Methaqualone: A positive test for Methaqualone is rare these days. The United States stopped manufacturing Quaaludes in Someone who tests positive for these would have to be buying them from an underground lab.
Opiates: Opiates are one of the most likely drugs to show positive on a drug test, as there are numerous medical uses for opiates. However, opiates are also commonly abused. Codeine, morphine, heroin, oxytocin, and hydrocodone all fall into this category of drugs. Make sure your employee is on a prescription for these drugs if they test positive. Phencyclidine: Phencyclidine is a common street drug known as PCP. There is no prescribed or medical use for this drug.
PCP is a mind-altering drug that causes hallucinations and has neurotoxic side effects. Be wary of a potential candidate that tests positive for PCP. Benzodiazepines: Testing positive for Benzodiazepines is very likely, as this drug class has extensive medical uses for various disorders.
Drugs including Xanax, Klonopin, Valium, Ativan, Lorazepam, and Restoril are all common benzodiazepines used to treat general anxiety disorders, insomnia, phobias, and panic disorders. These drugs are commonly prescribed, but also easy to find on the street. If a potential employee tests positive, ask to see their prescription to find if they are using Benzodiazepines legally. Methadone: Methadone is used to treat heroin, morphine, or opioid addiction. By law, only a SAMHSA certified treatment program can dispense Methadone, and patients receiving Methadone must receive the medication under the supervision of a practitioner.
We evaluated zolpidem use by patients who did and did not inform their pain provider. The measure of non-informed rates has been described elsewhere with tricyclic antidepressant use Two rates of non-informed usage were calculated, the non-informed provider percentage in the general population was 4. Although one of the most common comorbidities in chronic pain patients is insomnia, patients may not be aware of the relationship and may choose to refrain from disclosing zolpidem use.
Thus, healthcare providers must frequently update patient medication lists as well as educate their patients about the importance of disclosing all medications regardless of how benign it may seem or what condition the medication is treating.
Seventy-nine percent of zolpidem users with pain concurrently use an opioid Table II. Opioid detection rates were similar between cohorts with the exception of buprenorphine and hydrocodone Table II. However, no data were reported on concurrent buprenorphine and zolpidem use Determining the cause of different use patterns of zolpidem and opioids between cohorts is a further area of investigation.
Future research should examine detection rates with opioids and other non-benzodiazepine hypnotic medications e. Additionally, studies utilizing external urine data are needed to confirm the current study findings of the different detection rates of hydrocodone and buprenorphine associated with concurrent zolpidem use.
The most common benzodiazepine detected in zolpidem users in both cohorts was alprazolam. This result is in contrast with a previous study in pain patients, whereby the most commonly detected benzodiazepines were oxazepam and temazepam One reason for the discrepancy between studies is the different limit of quantitation for alpha-hydroxyalprazolam, which may have resulted in a larger number of positive specimens for alprazolam use.
This seems to also suggest a preference for a short-acting benzodiazepine in zolpidem users. Furthermore, zolpidem users in the unreported use cohort also had higher frequencies of concurrent use of an opioid and a benzodiazepine Figure 1 and concurrent use of an opioid, a benzodiazepine and an other medication with CNS depressant effects Of note, these rates may be underestimates as additional medications with CNS depressant effects, such as over-the-counter diphenhydramine, were not analyzed.
There is suggestion that patients with chronic pain who appropriately use or misuse opioid analgesics plus benzodiazepines and other CNS depressant medications have increased rates of adverse effects, overdose and death 7 , In special populations such as the older adult with chronic pain, they are at an even higher risk for adverse effects that may exacerbate falls, cognitive impairment and dementia The current study lacked dose amount and time of dose administration data for zolpidem.
Whether these factors impacted concurrent use with an opioid, benzodiazepine or other CNS depressants is unknown. Another study limitation was the presumption of medication use from physician-reported medication lists. Inaccurate medication lists were possible and could impact the results of our study. Studies have reported discrepancies upon comparing medication lists with what the patient is actually taking 21 , Although electronic health records have been suggested to increase medication list accuracy, the utility of such technologies remains low 23 , This was a data analysis in a pain population evaluating zolpidem use patterns by examining physician-reported medication lists and urine drug testing.
These results highlight the differences in the use patterns of zolpidem with different opioids and benzodiazepines. Furthermore, among patients using zolpidem, a large discrepancy This analysis also suggested pain patients taking zolpidem without the pain provider's knowledge are concurrently taking other medications with CNS depressant effects.
All health care providers need to be aware of the importance of accurate and timely medication reporting. Patient counseling on the anticipated side effects and the treatment duration course may improve the percentage of non-informed prescriber use.
Ideally if a sleep aid was needed, an open dialog would occur between the provider and the patient. Urine drug testing can be a helpful tool for providers to monitor reported and unreported drug therapy for patients with pain. The authors would like to acknowledge Amadeo J. Urine specimens were tested and provided by Millennium Laboratories. Dr Joseph D. Ma is a paid consultant of Millennium Laboratories, Inc. Google Scholar. Google Preview. Oxford University Press is a department of the University of Oxford.
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