Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

Marc R. Larochelle, Ricardo Cruz, Sarah Kosakowski, Doug L. Gourlay, Daniel P. Alford, Ziming Xuan, Erin E. Krebs, Shapei Yan, Karen E. Lasser, Jeffrey H. Samet, Jane M. Liebschutz

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. Objective: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. Design: Retrospective cohort study. Subjects: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. Main Measures: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. Key Results: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18–34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9–12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1–2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5–3.7]) were more likely to have a concerning UDT result. Conclusions: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.

Original languageEnglish (US)
Pages (from-to)2365-2372
Number of pages8
JournalJournal of general internal medicine
Issue number10
Early online dateAug 17 2021
StatePublished - Aug 17 2021

Bibliographical note

Funding Information:
This study was funded by the National Institutes of Health/National Institute on Drug Abuse K23DA042168.

Publisher Copyright:
© 2021, Society of General Internal Medicine.


  • chronic pain
  • opioid analgesics
  • urine drug tests


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