Clinical UM Guideline

 

Subject: Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
Guideline #:  CG-LAB-09 Publish Date:    01/31/2019
Status: Revised Last Review Date:    01/24/2019

Description

This document addresses the use of drug testing involving urine, blood, saliva, sweat, or hair samples in the outpatient setting for adherence monitoring of controlled substance use as part of the management of chronic pain and for individuals undergoing treatment for opioid addiction and substance use disorder.

Note: This document does not address the use of urine drug testing in the following circumstances:

Note: Drug testing or screening for employment issues may be addressed in the member certificate. Please refer to the member’s benefits for further information

Note: Sample validation is a method that is sometimes needed to assure source integrity. Quality assurance to assure sample integrity is part of expected clinical laboratory test management.

Note: For more information about drug testing sample validation, please see:

Clinical Indications

Medically Necessary:

Presumptive urine drug testing (UDT) to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate aberrant* behavior is considered medically necessary up to 24 times per year, beginning at the start of treatment, as part of a monitoring program tailored to the unique needs of individuals who are:

  1. Receiving treatment for chronic pain with prescription opioid or other potentially abused medications; or
  2. Undergoing treatment for, or monitoring for relapse of, opioid addiction or substance use disorder.

Presumptive urine drug testing is also considered medically necessary for the following:

  1. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or
  2. On initial entrance into a pain management program or substance use disorder recovery program.

Definitive urine drug testing to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate aberrant* behavior is considered medically necessary up to 24 times per year, beginning at the start of treatment, as part of a monitoring program tailored to the unique needs of individuals whose requests meet criteria both A and B below:

  1. Testing indications- either 1 or 2 below must be present:
    1. Receiving treatment for chronic pain with prescription opioid or other potentially abused medications; or
    2. Undergoing treatment for, or monitoring for relapse of, opioid addiction or substance use disorder;
      and
  2. Testing scenarios- either 1 or 2 below have been met:
    1. Definitive testing following prior presumptive testing:
      1. The presumptive urine drug testing was done for a medically necessary reason; and
      2. The presumptive test was positive for an illegal drug (for example, but not limited to methamphetamine or cocaine), positive for a prescription drug with abuse potential which was not prescribed, or negative for prescribed medications; and
        1. The specific definitive test(s) ordered are supported by documented rationale for each test ordered; and
        2. Clinical documentation reflects how the results of the test(s) will be used to guide clinical care;
          or
    2.  Definitive testing without prior presumptive testing:
      1. Presumptive urine drug tests are not available for the drug in question (examples may include, opioids and their metabolites such as fentanyl, meperidine, tramadol, and tapentadol, muscle relaxants and their metabolites such as carisoprodol, synthetic cannabinoids and their metabolites, as well as cathinones [“Bath Salts”] and their metabolites); and
      2. The specific definitive test(s) ordered are supported by documented rationale for each test ordered; and
      3. Clinical documentation reflects how the results of the test(s) will be used to guide clinical care.

*Aberrant behavior includes, but is not limited to, lost prescriptions, repeated requests for early refills, prescriptions from multiple providers, unauthorized dose escalation, and apparent intoxication.

Note: Each definitive test request must be based on the tested individual’s diagnosis, substance use patterns, results of presumptive testing and other clinical factors documented in the medical record. Community patterns of illicit drug use must not be imputed to an individual without a documented rationale. UDT monitoring of prescribed drugs is not a clinically appropriate way to estimate the therapeutic effectiveness of prescribed drugs.  Definitive testing for more than 7 classes of drugs (including metabolites) would be unusual for most individuals.

The use of blood samples as an alternative to urine for drug testing is considered medically necessary when the use of urine is not feasible (for example, when an individual has advanced kidney failure).

Not Medically Necessary:

The use of presumptive urine drug testing is considered not medically necessary when the criteria above are not met.

The use of definitive urine drug testing is considered not medically necessary when the criteria above are not met.

The use of presumptive or definitive testing panels is considered not medically necessary unless all components of the panel have been determined to be medically necessary based on the criteria above.  However, individual components of a panel may be considered medically necessary when criteria above are met.

The use of blood samples for drug testing is considered not medically necessary in all other circumstances, including when the criteria above have not been met.

The use of saliva, sweat, or hair samples for drug testing is considered not medically necessary in all circumstances.

The use of any of the following for definitive drug testing of urine or blood samples is considered not medically necessary in all circumstances:

  1. Reflex testing; or
  2. Standing orders; or
  3. Blanket orders.          
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

 

Presumptive Drug Class Screening codes:

80305

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]) includes sample validation when performed, per date of service

80306

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service

 

 

 

Definitive Drug Testing codes:

80320

Alcohols

80321

Alcohol biomarkers; 1 or 2

80322

Alcohol biomarkers; 3 or more

80323

Alkaloids, not otherwise specified

80324

Amphetamines; 1 or 2

80325

Amphetamines; 3 or 4

80326

Amphetamines; 5 or more

80327

Anabolic steroids; 1 or 2

80328

Anabolic steroids; 3 or more

80332

Antidepressants, serotonergic class; 1 or 2

80333

Antidepressants, serotonergic class; 3-5

80334

Antidepressants, serotonergic class; 6 or more

80335

Antidepressants, tricyclic and other cyclicals; 1 or 2

80336

Antidepressants, tricyclic and other cyclicals; 3-5

80337

Antidepressants, tricyclic and other cyclicals; 6 or more

80338

Antidepressants, not otherwise specified

80339

Antiepileptics, not otherwise specified; 1-3

80340

Antiepileptics, not otherwise specified; 4-6

80341

Antiepileptics, not otherwise specified; 7 or more

80342

Antipsychotics, not otherwise specified; 1-3 

80343

Antipsychotics, not otherwise specified; 4-6

80344

Antipsychotics, not otherwise specified; 7 or more

80345

Barbiturates

80346

Benzodiazepines; 1-12

80347

Benzodiazepines; 13 or more

80348

Buprenorphine

80349

Cannabinoids, natural

80350

Cannabinoids, synthetic; 1-3

80351

Cannabinoids, synthetic; 4-6

80352

Cannabinoids, synthetic; 7 or more

80353

Cocaine

80354

Fentanyl

80355

Gabapentin, non-blood

80356

Heroin metabolite

80357

Ketamine and norketamine

80358

Methadone

80359

Methylenedioxyamphetamines

80360

Methylphenidate

80361

Opiates, 1 or more

80362

Opioids and opiate analogs; 1 or 2

80363

Opioids and opiate analogs; 3 or 4

80364

Opioids and opiate analogs; 5 or more

80365

Oxycodone

80366

Pregabalin

80368

Sedative hypnotics (non-benzodiazepines)

80369

Skeletal muscle relaxants; 1 or 2

80370

Skeletal muscle relaxants; 3 or more

80371

Stimulants, synthetic

80372

Tapentadol

80373

Tramadol

80374

Stereoisomer (enantiomer) analysis, single drug class

80375

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3

80376

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6

80377

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more

83992

Phencyclidine (PCP)

0006U

Detection of interacting medications, substances, supplements and foods, 120 or more analytes, definitive chromatography with mass spectrometry, urine, description and severity of each interaction identified, per date of service
Drug-drug, Drug-substance Identification and Interaction; Aegis Sciences Corporation

0011U

Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites
Cordant CORE™; Cordant Health Solutions

0082U

Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography with mass spectrometry, and presumptive, any number of drug classes, by instrument chemistry analyzer (utilizing immunoassay), urine, report of presence or absence of each drug, drug metabolite or substance with description and severity of significant interactions per date of service
NextGen Precision™ Testing, Precision Diagnostics LBN Precision Toxicology, LLC

 

 

HCPCS

 

G0480

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase]), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed

G0481

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase]), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed

G0482

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase]), stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed

G0483

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays [e.g., IA, EIA, ELISA, EMIT, FPIA] and enzymatic methods [e.g., alcohol dehydrogenase]), stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed

G0659

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes

P2031

Hair analysis (excluding arsenic)

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Urine Drug Testing (UDT)

The use of UDT in individuals with a substance use disorder or undergoing opioid treatment for chronic pain conditions is common and serves several purposes. According to the American College of Physicians (ACP, 2008), the reasons for UDT include:

The American Pain Society (APS) and American Academy of Pain Medicine (AAPM) joint guidelines panel released their opioid treatment guidelines titled Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Non-cancer Pain in 2009 (Chou, 2009). In this document the AAPM addressed the monitoring of controlled substances use via UDT as part of a chronic opioid treatment (COT) program. The guideline section on monitoring (Section 5) states:

5.1 Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence).
5.2 In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence).
5.3 In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence). Clinicians should periodically reassess all patients on COT. Regular monitoring of patients once COT is initiated is critical because therapeutic risks and benefits do not remain static.

The American Society of Addiction Medicine (ASAM) published a document titled, Drug Testing: A White Paper of the American Society of Addiction Medicine (ASAM) (2013). This document details the critical issues that surround the topic of drug testing, including the various technologies available, testing of various body fluids and substances, when and why to test specific individuals, interpretation of test results, and the principles of testing in various settings. ASAM addresses many of the complicated issues surrounding quantitative testing, about which they state, “Definitive (also: “confirmatory” or "identification” testing) testing, which involves chromatography and mass spectrometry, incurs additional expense and thus should be done for specific indications.” As well as:

In general, positive IA [immunoassay] results need only be subjected to definitive testing when the results conflict with patients’ account of their drug use or when drug specificity is needed in class-specific assays (i.e. amphetamines, benzodiazepines, opiates). In a pain practice it is sometimes, but not always, important to identify the specific drug, not just the class of the drug. 

Overall, ASAM does not provide a supporting rationale for across the board definitive testing in any setting. 

Furthermore, they address the scheduling of drug testing and state the following:

When possible, random urine or oral fluid testing schedules are preferred to fixed testing schedules. Random testing involves notifying the individual of an immediate testing time and often involves escorting the individual to an observed testing site for specimen collection. While important in some settings, it is not feasible in others.

In 2017 ASAM published a document titled Appropriate Use of Drug Testing in Clinical Addiction Medicine (Jarvis 2017). In this publication the ASAM provided an array of recommendations related to UDT and other drug testing procedures. Regarding presumptive and definitive testing the document included the following recommendations:

Regarding testing frequency, ASAM recommended that:

Finally, ASAM recommended the following related to UDT:

*Point of care tests.

The exact frequency and pattern of urine drug screening is individualized based on the risk for abuse. The Washington State Agency Medical Directors' Group (AMGD) published an Interagency Guideline on opioid dosing for chronic non-cancer pain. This guideline and related expert commentary support low-risk individuals having UDT up to once per year, moderate-risk up to 2 per year, high-risk individuals up to 3-4 tests per year, and individuals exhibiting aberrant behaviors should be tested at the time of the office visit. The American Pain Society guidelines (Chou, 2009) state that for individuals at low-risk for adverse outcomes, quarterly or semi-annual monitoring is sufficient. For very high-risk individuals, weekly monitoring may be reasonable. However, the AMGD states that there is insufficient evidence to support this recommendation. This observation is reiterated in a review article by McMillin and colleagues (2013), where they comment that there is a lack of detailed guidelines addressing the appropriate use of DUT to support chronic pain management. The ASAM white paper does not recommend an upper limit for testing. However, in the context of abuse, McMillin et al. do recommend no less than testing once weekly at first then down to once monthly when abstinence is established. Such limitations apply to both presumptive and definitive testing. There is insufficient clinical reasoning to support the use of definitive testing at a frequency greater than for presumptive testing.

The risk for abuse may be measured using standard tools, such as the Screener and Opioid Assessment for Patients with Pain (SOAPP®; PainEdu.org, 2013) and the Opioid Risk Tool (Webster, 2005). These types of tools may help clinicians assess the suitability of long-term opioid therapy for chronic pain patients, and may help differentiate those patients who require more or less clinician monitoring while on long-term opioid therapy. The SOAPP tool is available for free and can be accessed at https://www.painedu.org/soapp.asp. There are four different versions available (5, 14, 24 questions and the Revised SOAPP [SOAPP-R]) allowing for varying levels of evaluation. All versions of the SOAPP tool may be self-administered at or prior to an office visit, or completed as part of an interview with a nurse, physician or psychologist. The ORT was developed by Webster et al. and has become widely used. Like the SOAPP, it may be self-administered or used as part of a clinical evaluation. A version of the ORT is available below. Other tools similar to the SOAPP and ORT are available elsewhere.

OPIOID RISK TOOL (ORT) (Webster, 2005)

Date: ____________________________                                                             

Name: ___________________________                                                         

                                                                                                                                                                               

                                                                                   Circle the score that applies:   

 

 

Mark each item that applies:

Item Score if Female

Item Score if Male

Family History of Substance Abuse

Alcohol
Illegal prescription drugs
Prescription drugs

_______
_______
_______
 

1
2
4

3
3
4

Personal History of Substance Abuse:

Alcohol
Illegal prescription drugs
Prescription drugs

_______
_______
­­­­­­­­­­_______
 

3
4
5

3
4
5

Age (Mark box if 16-45):

 

_______
 

1

1

History of preadolescent Sexual Abuse:

 

_______
 

3

0

Psychological disease:

Attention deficit disorder
Obsessive compulsive disorder
Bipolar
Schizophrenia
Depression

_______
_______
_______
_______
_______
 

Mark “2” if any, some
or all four Psychological diseases are present

         1                      1

Total

 

 

_______________
 

Risk categories: Low = 0-3; Moderate = 4-7; High ≥8

Another issue within the topic of UDT is the use of presumptive vs. definitive testing. Presumptive testing is intended to identify the use or non-use of a drug or class of drugs. Definitive tests are more specific, and allow for the detection of specific drugs or metabolites of interest. In most cases presumptive testing is used because it is quick, fairly accurate, and easily accessible in a wide variety of settings. Definitive testing may be needed when presumptive results alone are not sufficient to guide clinical care. However, in most situations, the identification or quantification of a specific drug of interest may not result in a different treatment plan. Definitive testing, particularly when performed repeatedly, must be clinically meaningful and documentation must support the specific necessity of each definitive assay performed as well as how that test result will affect clinical management.

Drug Testing of Blood, Saliva, Sweat, or Hair Samples

At this time, the use of samples other than urine, including blood, hair, saliva, and sweat, is not recommended by most authoritative organizations that provide guidance on drug testing, including the American Society of Addiction Medicine (ASAM, 2013, 2015), the ACP (Kirschner, 2014), the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM, Chou, 2010) and the Washington State Agency Medical Directors' Group (AMGD, 2010).

The ASAM (2013) does mention the use of blood, hair, saliva (oral fluid), and sweat, but they do not make specific recommendations on how, when, and why they should be used. The ASAM does provide comments on the benefits and drawback of these substrates. They state that urine is preferred as a sample substrate relative to blood because blood collection is invasive, poses significant difficulties in collecting, and the samples require extensive lab preparation. Furthermore, the ASAM noted that there is significantly shorter duration of active drug and metabolites in blood vs. urine. For hair samples, the ASAM guideline noted benefits including difficulty in falsifying sampling and a longer period of detection. However, it is noted that hair samples do not allow for the determination of when drugs were taken, and recent exposures cannot be detected. The ASAM guideline states that sweat patch testing techniques are fairly tamper resistant but vulnerable to unintentional or accidental damage. For saliva ASAM comments that while this method shares similar attractive attributes with urine, such as noninvasive collection and easy laboratory analysis, ASAM states that there is a much shorter duration of active drug and metabolites and lower detection rates vs. UDT. Their 2015 guideline titled “National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use” does not mention the use of blood, hair, saliva, or sweat samples for testing and recommend only urine drug testing at the standard methodology.

In the 2017 ASAM recommendations (Jarvis, 2017) they address the use of alternate sample matrices in the following statements:

While these recommendations support the use of oral fluid testing, the evidentiary basis for this is weak. 

The U.S. Department of Health and Human Services (DHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) has published two documents that address drug testing for individuals in primary care and substance abuse disorder treatment programs (SAMHSA, 2012, 2014). In these documents they discuss the benefits and drawbacks of drug testing using alternative sample sources. However, in their primary care document (2012) SAMHSA clarifies that urine is the most widely used and studied source. This was reiterated in their 2014 Treatment Improvement Protocol for opioid addiction programs.

However, in some circumstances the use of UDT is not possible. In the SAMHSA 2014 protocol they state, “Urine testing is not feasible for patients with renal failure (e.g., those on dialysis) or other bladder control impairments.”  In such circumstances the use of blood drug testing may be reasonable.

There is growing support for the use of saliva testing, especially in cases where a urine sample is unobtainable, when such results may be unreliable, or when there is a history of urine sample tampering. However, as noted above, there is little evidentiary support for this approach.

In summary, the use of blood, hair, saliva, and sweat is not widely recommended and these matrices each have significant drawbacks to their use when compared to UDT.

Testing Panels

Many commercial laboratories market multi-test panels for the presence of various prescription and illicit drugs and their metabolites. While the use of some individual tests included in these test panels may be reasonable under specific circumstances, the use of all the tests within a panel is rarely justified unless there is clinical evidence that an individual has used or been exposed to multiple substances, and knowledge of such exposure provides information that leads to meaningful impact on treatment.  

Reflex testing, Standing orders, and Blanket orders

The use of reflex testing, standing orders, and blanket orders for definitive testing of urine or blood samples is contrary to good clinical practice, which is based on clinical decision-making as to the necessity of specific laboratory tests. In the case of these types of tests, they are done in the absence of the requisite clinical decision making process, and based solely on automated processes devoid of clinical judgment. They do not meet the requirement for there to be documentation of a specific rationale for each ordered test and documentation of how the test will be used to modify treatment for the tested individual.

Definitions

Blanket order: A test request that is not for a specific individual, but it is an identical order for all individuals in a clinician’s practice. Such orders do not take the clinical situation of each individual into consideration at the time of request, or during each every visit.

Definitive testing: A type of testing that is more specific than presumptive testing, and allows for the detection of specific drugs or metabolites. 

Drug class: Drugs, medications or illicit substances (including metabolites of each member of the class) that share similar essential aspects of their chemical structure and at least one similar mechanism of action (i.e., bind to the same biological target). For example, opioids interact with one or more opioid receptor. Drugs associated with substance use disorders, including alcohol and inhalants, are thought to directly activate the brain reward system as a common mode of action.

Drug diversion: Prescription drugs provided to an individual other than the one to whom the drugs were prescribed.

Drug testing panel: A type of test that involves tests for more than one type of drug, and may test for a pre-defined set of drug classes or metabolites of specific drugs or drug classes.

Member-specific profile: This term refers to the specific characteristics of an individual being treated for chronic pain or an individual undergoing treatment for opioid addiction and substance use disorder, which may be used to help guide treatment. These characteristics may include current and past alcohol and drug use patterns and clinical findings such as slurred speech, hallucinations or pin-point pupils that tend to be specific to a drug or drug class. Use of member-specific profiles assist in guiding the selection of the specific tests for drugs and their metabolites. 

Planned testing: Testing being conducted at a time previously scheduled and known to the individual being tested.

Presumptive testing: A type of testing that is intended to identify the use or non-use of a drug or general class of drugs. 

Random testing: Testing being conducted at a time not previously scheduled and not known to the individual being tested.

Reflex Testing: A laboratory test that is performed "reflexively" after an initial or presumptive test result suggests the need for further diagnostic information. This type of testing is not based on a specific clinical situation and provider's order, but is built into the testing process. Testing performed as a step necessary to complete the request of physician responsible for a members care and provided by an order is not considered reflex testing.

Standing order: A test request for a specific individual representing: 1) repetitive testing to monitor a condition or disease, or 2) individualized orders for repetitive automatic testing for certain individuals for pre-determined tests based on historical use, risk, and community trend patient profiles. Definitive drug testing standing orders are not consistent with ordering laboratory testing based upon clinical findings, nor are they sensitive to the individual’s history of drug use and community patterns of drug use.

Testing panel: A type of laboratory procedure where multiple tests are automatically run on a single sample to detect the presence of a variety of substances or class of substances.

References

Peer Reviewed Publications:

  1. Christo PJ, Manchikanti L. Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011; 14(2):123-143.
  2. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012; 15(3 Suppl):ES119-ES133.
  3. Melanson SE. The utility of immunoassays for urine drug testing. Clin Lab Med. 2012; 32(3):429-447.
  4. Melanson SE, Ptolemy AS, Wasan AD. Optimizing urine drug testing for monitoring medication compliance in pain management. Pain Med. 2013; 14(12):1813-1820.
  5. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6(6):432-442.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Addiction Medicine. Drug testing: a White Paper of the American Society of Addiction Medicine (ASAM). October 26, 2013. Available at: http://www.asam.org/docs/default-source/publicy-policy-statements/-pdf-.pdf?sfvrsn=0. Accessed on January 24, 2019.
  2. American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use. 2015. Available at: http://www.asam.org/quality-practice/guidelines-and-consensus-documents/npg. Accessed on December 4, 2018.
  3. Chou R, Fanciullo GJ, Fine PG, et al.; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009. 10(2):113-130.
  4. Centers of Medicare and Medicaid, Complying with documentation requirements for laboratory services. August 2016. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/LabServices-ICN909221-Text-Only.pdf. Accessed on January 24, 2019.
  5. Jarvis M, Williams J, Hurford M, et al. Appropriate Use of Drug Testing in Clinical Addiction Medicine. J Addict Med. 2017; 11(3):163-173.
  6. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017; 20(2S):S3-S92.
  7. McMillin GA, Slawson MH, Marin SJ, Johnson-Davis KL. Demystifying analytical approaches for urine drug testing to evaluate medication adherence in chronic pain management. J Pain Palliat Care Pharmacother. 2013; 27(4):322-339.
  8. PainEDU.org. Opioid risk management. About the SOAPP. Available at: https://www.painedu.org/opioid-risk-management/. Accessed on January 24, 2019.
  9. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Medication-assisted treatment for opioid addiction in opioid treatment programs. A treatment improvement protocol TIP 43. 2014 Available at: https://www.asam.org/docs/advocacy/samhsa_tip43_matforopioidaddiction.pdf?sfvrsn=0. Accessed on January 24, 2019.
  10. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. National practice guideline for the use of medications in the treatment of addiction involving opioid use. 2015. Available at: http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf. Accessed on January 24, 2019.
  11. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Technical Assistance Publication Series 32: Clinical drug testing on primary care. 2012. Available at: http://www.ucdenver.edu/academics/colleges/PublicHealth/research/centers/CHWE/Documents/SAMHSA_drugtesting.pdf. Accessed on January 24, 2019.
  12. Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy. 2010 Update. Available at: http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed on January 14, 2019.
Index

Buprenorphine
Naloxone
Suboxone®

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. 

History

Status

Date

Action

Revised

01/24/2019

Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified MN statement for presumptive testing. Expanded MN statement regarding definitive testing. Added note regarding number of drug classes tested for during definitive testing. Updated Rationale and References sections.

  12/27/2018 Updated Coding section with 01/01/2019 CPT changes; added 0082U.

 

06/28/2018

Updated Coding section with 07/01/2018 CPT changes; revised descriptor for code 0006U.

Reviewed

03/22/2018

MPTAC review.

Reviewed

02/23//2018

Behavioral Health Subcommittee review. Updated References section.

 

12/27/2017

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT descriptor changes for codes 80305-80307.

Revised

08/03/2017

MPTAC review.

Revised

07/21/2017

Behavioral Health Subcommittee review. Updated formatting in Clinical Indications section. Added new NMN statement regarding reflex testing, standing orders, and blanket orders. Updated Description, Discussion, and References sections. Updated Coding section with 08/01/2017 CPT changes; added 0006U and 0011U.

 

01/01/2017

Updated Coding section with 01/01/2017 CPT and HCPCS changes; removed codes 80300, 80301, 80302, 80303, 80304, G0477, G0478, G0479 deleted 12/31/2016.

Reviewed

08/04/2016

MPTAC review.

Reviewed

07/29/2016

Behavioral Health Subcommittee review. Updated Discussion and References sections.

Revised

02/05/2015

MPTAC review.

Revised

01/29/2016

Behavioral Health Subcommittee review. Revised title to change “Substance Abuse” to “Substance Use Disorder”. Added the use of blood, saliva, sweat, or hair to position statement. Revised Background, Coding and References sections.

 

01/01/2016

Updated Coding section with 01/01/2016 HCPCS changes, removed codes G0431, G0434, G6031, G6040, G6041, G6042, G6043, G6044, G6045, G6046, G6048, G6051, G6052, G6053, G6056, G6057, G6058 deleted 12/31/2015; also removed ICD-9 codes.

Revised

02/05/2015

MPTAC review.

Revised

01/30/2015

Behavioral Health Subcommittee review. Revised clinical indications section to address “presumptive” and “definitive” testing. Clarified the limit of 24 tests per calendar year to be a rolling 24 year. Updated Discussion, Definitions, and References sections.

 

01/01/2015

Updated Coding section with 01/01/2015 CPT and HCPCS changes; removed deleted codes and codes 80184, 82491, 82492, 82541, 82542, 82543, 82544 (no longer applicable). 

Revised

02/13/2014

MPTAC review.

Revised

02/07/2014

Behavioral Health Subcommittee review. Added not medically necessary statement addressing the use of testing panels. Updated Discussion, Definitions, and References sections.

New

11/14/2013

MPTAC review. Initial document development.