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This policy addresses urine drug testing in patients with chronic non-cancer pain who are on chronic opioid therapy. Chronic non-cancer pain is pain in which the causes cannot be removed or otherwise treated and no relief or cure has been found after reasonable efforts. Chronic opioid therapy is daily or near-daily doses of opioid medication. Compliance monitoring has been shown to be crucial in delivering proper opioid therapy and preserving this therapy for the future.

Urine drug testing (UDT) is a widely available and familiar method for monitoring opioid use in chronic pain patients. UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient’s predisposition to, and patterns of,  misuse/abuse – a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain.

Frequency of Testing

A practical approach to UDT would include baseline drug testing, if appropriate; initiation of opioid therapy, and compliance monitoring within one to 3 months after baseline monitoring; and routine, random monitoring approximately every 6-12 months.  Thus, the majority of patients will receive a baseline test, initiation of the compliance test, and one year monitoring within the first 15 months or so. After that, if the patient is continuing with a pain management program, testing will only be required once a year.

Types of Urine Drug Tests

Two types of urine drug screens are typically used, immunoassay and gas chromatography–mass spectrometry. Several factors need to be considered to determine the length of time a drug or substance can be detected in the urine, including:

• pharmacokinetics
• presence of metabolites
• patient variability (eg, body mass)
• short-term vs. long-term use of a drug
• pH of the urine
• time of last ingestion

Urine drug testing for monitoring opioid use in patients with chronic non-cancer pain may be considered medically necessary up to two (2) times per year, unless there are inconsistencies (abnormalities) in the urine drug test results. 

A confirmatory urine drug test is considered medically necessary only when there were inconsistencies (abnormalities) in the urine drug test results. 

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Urine Drug Testing In Chronic Pain: Comprehensive Review, Paul J. Christo, MD1, Laxmaiah Manchikanti, MD2, Xiulu Ruan, MD3, Michael Bottros, MD1, Hans Hansen, MD4, Daneshvari R. Solanki, MD5, Arthur E. Jordan, MD6, and James Colson, MD7 Pain Physician 2011; 14:123-143 • ISSN 1533-3159 http://www.painphysicianjournal.com/2011/march/2011;14;123-143.pdf

Urine Drug Screening: A Practical Guide for Clinicians Karen E. Moeller, Kelly C. Lee, Julie C. Kissack, Mayo Clinic Proceedings, 2008 83(1): pp 66–76
http://www.mayoclinicproceedings.org/article/S0025-6196(11)61120-8/fulltext

Chronic Opioid Therapy (COT) Safety Guideline For Patients With Chronic Non-Cancer Pain, Copyright 2010–2012 Group Health Cooperative
http://www.ghc.org/all-sites/guidelines/chronicOpioid.pdf

Covered Codes

This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

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