Urine Drug Testing in the Treatment of Chronic Noncancer Pain in a Kentucky Private Neuroscience Practice: The Potential Effect of Medicare Benefit Changes in Kentucky

Background: Because the symptoms of drug misuse are nonspecific and difficult to detect,pain physicians have relied heavily on the results of urine drug tests to diagnose and treatchronic noncancer pain in patients who are prescribed controlled substances. However, changesin Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana,Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screeningwas no longer recognized as medically reasonable and necessary in the treatment of patients withchronic noncancer pain unless the patient presents with suspected drug overdose.Study Design: A retrospective review of urine drug testing services.Objective: To determine the extent of urine drug testing in patients with chronic noncancerpain in a large, Kentucky neuroscience practice offering pain management services combined withneurologic and neurosurgical services to better understand the potential effects of recent changesto Medicare benefits.Methods: An audit of services provided during 2007 was conducted using computer software.Outcome Measures: Outcome measures included the number of practice services, number of urinedrug tests by payor, and the number of noncompliant patients by payor who self-released from care.Results: Urine drug tests represented approximately 18.2% of professional medical services rendered in2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients.In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice.Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40%of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests werealso instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of thesepatients, approximately 60% were government insured.Limitations: Not a prospective, double-blinded study. We approximated the proportion ofpatients potentially affected by drug abuse or addiction as the percentage of patients self releasingfrom medical care.Conclusion: In 2007, UDTs were used as an effective tool in adherence monitoring in a privateneuroscience practice in Kentucky that offers pain management services combined with neurologic andneurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatmentby behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signsof drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were governmentinsured. Should the objective and reliable sign offered by UDTs be eliminated from the physician’s toolbox,the physician’s ability to accurately diagnose and treat these patients could be impaired.Key words: Chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse