Appendix II: Administrative Protocols: Failure to Provide UDT and Unexpected Results

While clinical administration does not need to be familiar with how to interpret UDT, they should be familiar with when to communicate to the prescriber either concerning automated interpretations on START-IT, or repeated failures to provide UDT. This section covers how clinical administration should respond to these concerning scenarios…

Unexpected results:
This section really only applies if you are using START-IT for automated UDT interpretation, or if you have been trained in how to interpret IA results. There are numerous different types of unexpected results, some more concerning than others, but generally speaking you should notify the opioid-prescribing physician of any unexpected result. Possible exceptions to this include those patients that may routinely have unexpected UDT, such as “Level 6” patients prescribed opioids as part of OAT for addictions treatment.

In addition to notifying the prescribing physician, follow the clinic policy around sending for confirmatory testing. At our clinic, we have historically sent all urines to the lab for confirmatory testing. START-IT now makes recommendations about when to send for confirmatory testing as well depending on the level of discordance between patient self-reports and the IA result. Unexpected results in which the patient self-report is discordant with the observed IA result will automatically result in a “strong” recommendation for confirmatory testing.

Equivocal results:
This also only applies if you are using START-IT for automated UDT interpretation, or if you have been trained in how to interpret IA results. There are some UDT results that are not fully unexpected, but not expected either. An example of this would be someone who is prescribed morphine but claims to have not taken it in the last week and UDT is negative for morphine. This result could be simply because the patient is prescribed morphine for intermittent pain flares and hasn’t had any recently, or alternatively it could mean that he either took too much of his medication early in his refill or is even diverting the morphine (trading/selling). If you are not sure what to do with the result, we recommend you notify the prescribing physician.

Failure to Provide UDT:
There are numerous reasons that a patient may be selected for UDT but fail to provide one. While the exact reason may be important (on one side of the spectrum is someone who is hospitalized for medical illness so can’t make it in, and on the other side is someone who doesn’t pick up the phone or return messages, or outright refuses), the bottom line is that someone who fails to provide a urine sample despite numerous attempts (arbitrarily 3 attempts, with variability depending on reasons for failure to provide UDT) has a soft concern that may affect if and how the physician prescribes opioids. The physician needs to know this. Message the physician with an explanation of the attempts that have been made and the patient’s response or lack thereof.

It is probably easiest to keep track of each attempt using the “Recall List” tab in the “HARMS Program UDT Randomization” spreadsheet (same one that keeps the master-list and randomizes patients).

Chapter Pearls

  • A patient failing to provide a UDT may be concerning. If repeated attempts are made then the prescribing physician should be notified, with as much detail as you have, so that action can be considered.