What is the next step for a patient (pt) who has signed a controlled substance agreement and tested positive for tetrahydrocannabinol (THC) and amphetamines?

From the Guidelines

The next step for a patient who has signed a controlled substance agreement and tested positive for THC and amphetamines is to schedule an immediate follow-up appointment to discuss the test results and consider discontinuing controlled substance prescriptions with a safe tapering plan if physical dependence is present. The provider should conduct a non-judgmental but direct conversation about the positive drug screen, review the terms of the controlled substance agreement, and assess whether there are legitimate medical explanations for the positive results (such as prescribed Adderall or dextroamphetamine for ADHD, or medical marijuana authorization) 1. If no valid medical explanation exists, the provider should consider alternative non-controlled pain management strategies such as non-opioid analgesics, physical therapy, or interventional pain procedures, as opioids should not be considered first-line or routine therapy for subacute or chronic pain 1. The provider should also screen for substance use disorder, offer referral to addiction treatment services, and consider the potential risks of opioid therapy, including overdose, respiratory depression, and death, particularly when combined with other substances such as benzodiazepines or alcohol 1. Additionally, the provider should discuss the importance of periodic reassessment to ensure that any ongoing treatment is helping to meet patient goals and, if not, to allow opportunities for consideration of tapering and dosage reduction or discontinuation and of additional nonpharmacologic or nonopioid pharmacologic treatment options 1. It is also crucial to consider the potential for substance use disorder, as amphetamine use can be associated with an increased risk of stroke, and referral to an appropriate therapeutic program may be reasonable for patients who abuse drugs that have been associated with stroke 1. Overall, the approach should balance patient safety with appropriate consequences for violating the agreement, as continuing to prescribe controlled substances when a patient is using illicit substances increases risk for adverse drug interactions, respiratory depression, and overdose.

From the Research

Next Steps for a Patient Who Tested Positive for THC and Amphetamines

• If a patient who has signed a controlled substance agreement tests positive for tetrahydrocannabinol (THC) and amphetamines, the next steps may involve a review of the patient's treatment plan and potential changes to their medication regimen 2.
• The patient's healthcare provider may also conduct further testing, such as urine drug testing, to confirm the presence of these substances and to monitor the patient's adherence to their treatment plan 3.
• The use of alternative matrices, such as oral fluid or exhaled breath, may also be considered for drug abuse screening in patients with substance use disorder 4.
• It is essential to interpret urine drug test results correctly to avoid misinterpretation and potential adverse consequences for the patient 5.
• The implementation of a Schedule II patient agreement for opioids and stimulants can help reduce the risk of medication diversion, abuse, and overdose, and improve adherence to monitoring requirements 2.
• The use of high-resolution mass spectrometry (HRMS) can help detect new psychoactive substances and improve the accuracy of drug testing results 6.

Considerations for Healthcare Providers

• Healthcare providers should be aware of the potential for patients to misrepresent their substance use and should use urine drug testing and other monitoring tools to ensure patient safety and adherence to treatment plans 3.
• The selection of the most appropriate drug testing method depends on the specific circumstances and purpose of the testing, and healthcare providers should consider the advantages and limitations of each method 4.
• Healthcare providers should also be aware of the potential for false-positive and false-negative results and should interpret urine drug test results in the context of the patient's medical history and other clinical information 5.