What action should be taken when a patient on opioid medication tests negative for the drug and its metabolites three times?

Management of Patients with Multiple Negative Opioid Drug Tests

When a patient on opioid medication has three negative drug tests for the prescribed opioid and its metabolites, the clinician should discontinue the prescription without a taper, as this confirms the patient is not taking the prescribed medication. 1

Understanding Negative Opioid Drug Tests

Negative drug tests for prescribed opioids can indicate several scenarios:

• Patient is not taking the medication as prescribed
• Patient is diverting the medication
• Patient has discontinued the medication without informing the provider
• Rarely, there may be metabolic or laboratory issues affecting test results

Appropriate Action Algorithm

Step 1: Confirm the Results

• Discuss unexpected results with the patient before ordering confirmatory testing
• If explanation is not provided, order confirmatory testing using gas or liquid chromatography/mass spectrometry to differentiate specific opioids and metabolites 1

Step 2: Evaluate the Pattern

• Single negative test: Investigate possible causes
• Multiple negative tests (three or more): Strong evidence of non-adherence
• Document all findings in the medical record

Step 3: Take Action Based on Confirmed Results

• For repeatedly negative tests confirming the patient is not taking the prescribed opioid:
  • Discontinue the prescription without a taper 1
  • No tapering is necessary since the patient is not physically taking the medication

Step 4: Address Underlying Issues

• Discuss findings with the patient
• Assess for substance use disorder
• Consider referral for substance use disorder treatment if appropriate 1
• Evaluate alternative pain management strategies

Important Clinical Considerations

• Do not dismiss patients from care based solely on drug test results, as this could constitute patient abandonment and have adverse consequences for patient safety 1
• Unexpected results should be used to improve patient safety through appropriate changes in pain management strategy
• Patients with repeatedly negative tests may be diverting their medications, which poses significant public health risks

Common Pitfalls to Avoid

1. Failing to have a plan for responding to unexpected results before ordering urine drug testing 1, 2
2. Dismissing patients from care based solely on drug test results 1
3. Not explaining to patients that urine drug testing is intended to improve their safety
4. Ordering definitive testing without clear indications of unexpected or inconsistent presumptive test results 2
5. Not discussing unexpected results with the laboratory or toxicologist and with the patient

Documentation Requirements

Ensure thorough documentation of:

• Discussion with patient about unexpected results
• Confirmatory testing results
• Clinical decision-making process
• Plan for alternative pain management if opioids are discontinued

By following this structured approach, clinicians can appropriately respond to repeated negative opioid drug tests while maintaining patient safety and adhering to best practices in pain management.