What is the recommended frequency for drug testing and medication contracts in patients on chronic scheduled medications, such as opioids (narcotic analgesics) or benzodiazepines (central nervous system depressants)?

From the Guidelines

The recommended frequency for drug testing and medication contracts in patients on chronic scheduled medications like opioids or benzodiazepines is typically every 3 months, with more frequent testing (every 1-3 months) for higher-risk patients and less frequent testing (every 6-12 months) for stable, low-risk patients. When considering the management of patients on chronic scheduled medications, it's crucial to balance the benefits of therapy with the risks of misuse, diversion, and the development of substance use disorders. The approach to monitoring should be individualized based on the patient's risk factors, including history of substance abuse, mental health conditions, and current medication regimen. Medication contracts should be reviewed and renewed annually, with the initial agreement established before starting therapy, and should clearly outline expectations regarding medication use, refill policies, and consequences of non-compliance. Random drug testing is often more effective than scheduled testing for detecting misuse, and the testing panel should include the prescribed medication to confirm adherence, as well as common drugs of abuse to detect potential misuse, as suggested by 1. This monitoring approach helps ensure patient safety by identifying potential medication misuse, diversion, or the development of substance use disorders, and also protects providers by documenting due diligence in prescribing controlled substances. Key considerations include:

• Patient risk factors, such as history of substance abuse or mental health conditions
• Medication regimen, including dose and type of medication
• Frequency of monitoring, with more frequent testing for higher-risk patients
• Use of medication contracts and random drug testing to detect misuse
• Importance of individualizing the approach to monitoring based on patient-specific factors, as noted in 1. By taking a comprehensive and individualized approach to monitoring patients on chronic scheduled medications, healthcare providers can minimize the risks associated with these medications while maximizing their therapeutic benefits, as recommended by 1.

From the FDA Drug Label

Continually reevaluate patients receiving morphine sulfate tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse [see Warnings and Precautions (5. 1)].

The FDA drug label does not provide specific recommendations for the frequency of drug testing and medication contracts for patients on chronic scheduled medications, such as opioids or benzodiazepines.

• However, it emphasizes the importance of continual reevaluation and monitoring for signs of addiction, abuse, or misuse.
• It also recommends a multimodal approach to pain management, including mental health support, prior to initiating an opioid analgesic taper 2.
• Additionally, the label highlights the need for counseling patients on safe use, serious risks, storage, and disposal of these products, as part of the Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) 2.

From the Research

Frequency of Drug Testing

• The frequency of drug testing for patients on chronic scheduled medications, such as opioids or benzodiazepines, is not strictly defined, but it is recommended to periodically undergo urine drug testing to confirm adherence to the treatment plan 3.
• Urine drug testing is an indispensable tool for therapeutic drug monitoring, which helps to ensure the continued safety of patients on chronic opioid therapy 3, 4.
• The use of urine toxicology testing may reveal the presence of illicit drugs, such as heroin or cocaine, or controlled substances not prescribed by the physician ordering the test 4.

Medication Contracts

• Opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain 5.
• However, there is little evidence as to the efficacy of opioid contracts, and their use may destroy patients' trust, which can impact health outcomes 5.
• The main purpose of the contract is to improve care through better adherence to opioid therapy, but statistics and evidence suggest that opioid contracts are unenforceable and lack efficacy 5.

Risk Factors for Aberrant Results

• Aberrant urine drug test results are more likely among patients under the age of 45, current smokers, and those with prior substance use disorder diagnoses 6.
• Other risk factors for aberrant results include males, patients with prior substance use disorder diagnoses, and current smokers 6.
• Patients on long-acting opioids only or long-acting plus short-acting opioids have lower odds of aberrant results compared to those on short-acting only 6.

Patterns of Opioid Use

• Symptomatic use of opioid medication (e.g., taking an opioid in response to increased pain) is more common than scheduled or strategic use of opioid medication 7.
• Symptomatic use of opioids is associated with poorer pain-related mental health, after controlling for pain duration and pain-related physical functioning 7.
• Use of opioids in a scheduled pattern is associated with better pain-related mental health 7.