INTRODUCTION

Urine drug testing (UDT) is a standard recommendation for those prescribed long-term opioid therapy (LTOT) for pain,1 but remains underutilized.2 Clinician fears regarding negative patient perceptions have been identified as a barrier to conducting UDT;3 however, little is known about patient perspectives of UDT. This study sought to uncover patients’ beliefs regarding UDT and its implications for the patient–clinician relationship.

METHODS

These data are a secondary analysis from a larger, IRB-approved study.4 Informed consent was obtained from all participants. Eligible participants received care at VA Portland Health Care System and were prescribed opioids for 90+ days for chronic musculoskeletal pain. Participants completed structured visits every 6 months for 24 months from 2013 to 2017. UDTs were completed as part of clinical care, not study procedures. At the final study visit, survey questions asked participants to choose between fixed response categories; open-ended questions probed experiences and perspectives regarding UDT. Qualitative data were double-coded by two research team members and categorized into themes. Representative quotes are presented in the text and Table 1.

Table 1 Patient Perspectives of Urine Drug Testing and Impacts on the Patient–Clinician Relationship
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RESULTS

The questionnaire was completed by 145 participants. Participants were primarily white (88%), and male (90%) with average age 62 (SD = 10.1, range = 34–87).

Overall, participants were indifferent to UDT and felt it did not impact the patient–provider relationship. This was captured in comments like, “It’s just like when they ask you to do a lab test, it’s no big deal.” The ubiquity of UDT (e.g., in the military or workplace) had normalized testing, and UDT was generally viewed as clinicians “just doing their job.”

Participants understood UDT as a sensible and necessary component of clinical care. As one participant stated, “They make perfect sense. If they [clinicians] are going to supply them [opioid medications], then obviously there should be some sort of monitoring.” For some, guidelines in the opioid treatment agreement primed their expectations for UDT; others couched their beliefs within the context of the opioid crisis, “… they’re absolutely necessary. I’m just one guy and I know I take it but if you’re a doctor I can’t imagine what stories they get.” These participants understood that their own clinical care was embedded within a larger landscape, and thus UDT did not reflect clinicians’ beliefs about them personally. UDT was also viewed as an important means of protecting health and safety. As one participant described, “I don’t mind doing what it takes to be safe.” Participants recognized that opioid medications were “powerful” and “potentially dangerous,” and thus UDT “… might end up saving somebody’s life in the end.” Further, as one participant described, “It actually made our relationship even stronger. I can deal with anything that is required … as long as you … tell me the truth about what it really is.” For some participants, UDT opened lines of communication, eliminated clinicians’ doubts about their behavior, and indicated concern for their well-being.

A small minority expressed dissatisfaction with UDT and described it as worsening the relationship with their clinician. For these participants, UDT evidenced a lack of trust, “You think…well they don’t trust you. But I realize it’s not personal.” Others did take UDT personally describing it as “invasive,” and “a violation of privacy.”

These findings are mirrored in the survey results (Table 2), where nearly 90% of participants recognized the benefits of UDT or were indifferent to them and described no change in their relationship as a result of UDT.

Table 2 Patient Perspectives of Urine Drug Testing and Impacts on the Patient–Clinician Relationship (n = 145)
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DISCUSSION

Routine UDT of patients prescribed LTOT remains underutilized, in part due to clinician concerns about patient perceptions.3 Our results suggest that clinicians’ fears may be misplaced. Patients were largely indifferent to UDT and understood it to be a standard aspect of care, motivated by a desire to protect their health. The broader context of the opioid crisis framed patient understanding of the need for UDT, as many were aware of the consequences of opioid misuse and abuse, which UDTs are designed to identify. To assuage concerns among the small minority of patients with negative perceptions of UDT, clinicians may wish to emphasize that the decision to utilize UDT is not personal, but a standard aspect of clinical care generally driven by desires to improve safety.5 Overall, these data suggest that fears of negative patient perceptions should not deter clinicians from conducting UDTs.