What is the best course of action for a patient with chronic pain on opiates (opioid analgesics) who has a recent positive urine test for cocaine?

Management of Chronic Pain Patients on Opioids with Positive Cocaine Urine Test

When a patient on chronic opioid therapy tests positive for cocaine, providers should conduct a thorough assessment, implement enhanced monitoring, consider referral for substance use treatment, but should not abruptly discontinue opioid therapy as this violates the principle of nonabandonment and may lead to worse outcomes. 1

Initial Response to Positive Cocaine Screen

1. Verify the result with confirmatory testing

   • Immunoassay-based tests can have false positives and should be confirmed with gas chromatography/mass spectrometry (GC-MS) or liquid chromatography/mass spectrometry (LC-MS/MS) 2
   • Document the confirmation before making clinical decisions 2

2. Clinical assessment

   • Discuss the test result with the patient in a non-judgmental manner 1
   • Explore potential reasons for cocaine use:
     • Self-medication for inadequate pain control
     • Substance use disorder
     • Psychological factors (anxiety, depression)
     • Social factors influencing drug use

Risk Stratification

Assess the patient for:

• Overdose risk factors:

  • Concurrent use of benzodiazepines or other sedatives 1
  • History of prior overdose 1
  • High-dose opioid therapy (>50-90 MME/day) 1
  • Respiratory conditions or sleep apnea 1

• Addiction risk factors:

  • History of substance use disorders 1
  • Mental health conditions 1
  • Family history of addiction

Management Plan

1. Enhanced Monitoring

• Increase frequency of visits and urine drug testing 1

  • Consider switching from random to scheduled UDT to increase opportunities for detection 1
  • Document all monitoring in the medical record

• Review and update opioid treatment agreement 1

  • Ensure patient understands the risks of combining opioids with cocaine
  • Clearly outline consequences of continued cocaine use

2. Pain Management Modifications

• Reassess pain control

  • Consider if inadequate pain control is driving substance use
  • Optimize non-opioid and non-pharmacological pain treatments 1

• Consider opioid dose adjustments

  • If continuing opioids, maintain lowest effective dose 1
  • Use caution when prescribing doses >50 MME/day and avoid exceeding 90 MME/day if possible 1

3. Substance Use Disorder Treatment

• Refer for substance use evaluation and treatment 1

  • Consider referral to addiction specialist or substance use treatment program
  • For patients with opioid use disorder, consider medication-assisted treatment with methadone or buprenorphine 1

• Address underlying factors

  • Screen for mental health conditions that may contribute to substance use
  • Consider psychosocial interventions to address triggers for cocaine use

4. Harm Reduction

• Provide overdose prevention education 1

  • Prescribe naloxone and educate patient and family on its use 1
  • Warn about increased overdose risk when combining opioids with cocaine

• Safe storage and disposal education 1

  • Educate on secure storage of medications
  • Provide information on proper disposal of unused medications

Follow-up Plan

1. Short-term follow-up (within 1-2 weeks)

   • Reassess pain control and medication adherence
   • Repeat urine drug testing
   • Evaluate engagement with referrals

2. Long-term monitoring

   • Regular urine drug testing (frequency based on risk level)
   • Ongoing assessment of pain control and functional status
   • Continued evaluation for signs of substance use disorder

Important Caveats

• Avoid patient abandonment

  • Never discharge patients from practice solely based on UDT results 1
  • Unexpected UDT results should prompt reevaluation of treatment strategy, not termination of care 1

• Consider false positives

  • Certain medications can cause false positive results for cocaine 2
  • Always confirm positive screening results with more specific testing 2

• Document thoroughly

  • Record all discussions, test results, treatment plans, and rationale for decisions
  • Include patient's response to interventions and counseling

By implementing this structured approach, providers can address the complex needs of chronic pain patients who test positive for cocaine while maintaining therapeutic relationships and prioritizing patient safety.