What is the best course of action for a patient with chronic pain, referred to a pain specialist, requesting a stronger opioid medication such as Norco (hydrocodone and acetaminophen) 10-325 mg, who has not completed a urine drug test?

Management of Chronic Pain Patient Requesting Stronger Opioids Without Completed Urine Drug Testing

Primary Recommendation

Do not prescribe stronger opioid medication (Norco 10-325 mg) or provide a referral to another pain specialist until the patient completes the urine drug test and you conduct a comprehensive risk-benefit reassessment. 1

Immediate Actions Required

Complete Urine Drug Testing First

• Baseline urine drug testing should be universal and mandatory before any opioid prescribing or dose escalation. 1
• Requiring baseline UDT in all patients establishes a standard that reduces stigma and eliminates biased assumptions about which patients use illicit substances. 1
• UDT provides objective data on undisclosed medications, nonuse of prescribed medications, and use of illegal drugs that may otherwise go undetected. 2
• The test must be completed before making any decisions about increasing opioid strength or changing providers. 1

Interpret UDT Results Carefully

• Establish a working relationship with your local toxicologist who can consult on results interpretation, as many providers have inadequate training in UDT interpretation. 1
• Use confirmatory testing (gas chromatography/mass spectrometry) to differentiate false positives from immunoassay screening tests. 1
• Consider a broad differential diagnosis before taking action on unexpected results: inadequate analgesia, substance use disorders, tolerance development, opioid-induced hyperalgesia, or self-medication of psychiatric symptoms. 1

Risk Assessment and Monitoring Framework

Before Any Opioid Escalation

• Evaluate whether expected benefits for both pain AND function outweigh risks—not just pain reduction alone. 3
• Establish clear treatment goals for pain and function with documented functional outcomes. 3
• Review prescription drug monitoring program (PDMP) data before any changes. 3
• Prescribe naloxone given the inherent overdose risk with opioid therapy. 3

Non-Opioid Alternatives Must Be Optimized First

• Non-pharmacologic and non-opioid pharmacologic therapies are the preferred treatment for chronic pain, even in patients already on opioids. 3
• Consider trial of antidepressants (nortriptyline 10-150 mg/day, duloxetine 30-60 mg/day) for neuropathic pain components. 1
• Consider trial of anticonvulsants (gabapentin 100-1200 mg three times daily, pregabalin 100-600 mg/day divided in 2-3 doses). 1
• Consider topical agents such as lidocaine 5% patch for localized pain. 1

Critical Pitfalls to Avoid

Do Not Abandon the Patient

• Unexpected UDT results and concerning behaviors should NOT be used to discharge patients from practice—this violates the principle of nonabandonment and undermines the therapeutic relationship. 1
• Instead, use these results in combination with other clinical data to reevaluate the current treatment strategy, including the risk-benefit ratio of opioid therapy. 1

Do Not Misinterpret Drug-Seeking Behavior

• Drug-seeking behavior may represent pseudoaddiction (legitimate attempts to obtain relief from uncontrolled pain) rather than true addiction. 3, 4
• A positive UDT is only a moderately positive predictor of prescription opioid misuse and requires clinical context. 1
• For patients in whom the prescribed substance is absent from urine, consider diversion, levels below screening threshold, or dilution before assuming misuse. 1

If Opioid Escalation Is Considered After UDT

Dosing Principles for Hydrocodone/Acetaminophen

• Continually reevaluate patients to assess maintenance of pain control and relative incidence of adverse reactions, as well as monitoring for development of addiction, abuse, or misuse. 5
• If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the dose. 5
• Monitor for acetaminophen hepatotoxicity risk with combination products, especially at higher doses. 5, 6

Monitoring Schedule

• Evaluate benefits and harms within 1-4 weeks of any dose change, and every 3 months thereafter. 3
• Perform urine drug testing periodically (every prescription to every 3 months). 3
• Review PDMP data at each visit or prescription. 3

Addressing the Referral Request

When Referral to Another Pain Specialist Is Appropriate

• For resistant pain not responding to multimodal therapy including interventional strategies. 1
• When specialized interventional procedures may be beneficial. 1
• However, the referral should not be made to circumvent completing the UDT or to obtain stronger opioids without proper risk assessment. 1

Establish Clear Expectations

• Use informed consent and patient-prescriber agreements to ensure patients understand treatment goals and potential opioid risks. 1
• Establish clear agreements regarding number of pills dispensed, frequency of use, and expected duration of treatment. 7
• Frequent face-to-face assessments are essential for monitoring benefit and opioid misuse. 1

Safe Opioid Management Principles

If Discontinuation or Dose Reduction Is Needed

• Do not abruptly discontinue opioids in patients who may be physically dependent—rapid discontinuation has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide. 5
• Initiate taper by small increments (no greater than 10-25% of total daily dose) to avoid withdrawal symptoms. 5
• Proceed with dose lowering at an interval of every 2-4 weeks. 5
• Ensure multimodal approach to pain management, including mental health support if needed, is in place prior to initiating taper. 5