Demystifying Medicine One Month at a Time

Tag: opioids

Solid Reporting on Liquid Gold

A thousand or more cups of urine arrive most nights by express mail to Comprehensive Pain Specialists clinics. The samples are tested for narcotics and other drugs, both legal and illegal. (Heidi de Marco/KHN)

In a beautifully reported investigative piece, Fred Schulte and Elizabeth Lucas of Kaiser Health News detail the explosive growth of the urine drug testing industry in the U.S.

We’ve written about this once before (more than 4 years ago!), but the growth of the industry fueled by taxpayer dollars (Medicare payment for drug testing) appears to be continuing unabated.

In this new piece, Schulte and Lucas do an expose on an outfit called Comprehensive Pain Specialists, a physician-owned outpatient pain management practice with 54 clinics across 10 states in the southeast U.S.

Let me be clear that CPS is not being singled out for malfeasance — rather, the point of the article is that they are emblematic of a huge surge in Medicare spending for expensive urine drug tests — many of which may be unnecessary.

Ay, there’s the rub. From the piece:

     …there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

The other thing that has government watchdogs and other observers worried is that for many pain specialists, the lion’s share of their revenue is earned by these drug tests. Remember, reasons to order these tests are twofold:

  1. Make sure patients ARE taking the drugs that you are prescribing (therefore suggesting that said drugs are not being diverted–e.g. sold on the street).
  2. Make sure patients AREN’T taking drugs of abuse (which for many pain clinics is a violation of the clinic-patient ‘pain management contract’).

As one government attorney was quoted:

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

The excellent bar graph attached below is included with the KHN story– and clearly demonstrates the trend. What are your thoughts?



Liquid Gold

Barry Meier is a journalist for the NY Times. [That’s one of those newspaper thingies that people of a certain age still read.] He recently wrote an e-book about abuse of prescription drugs called A World of Hurt: Fixing Pain Medicine’s Biggest Mistake. Seems to be selling well.

His reporting and his book highlight the growing U.S. death rate from overdose of prescription pain medicine. He’s definitely entered the fray—some people applaud him as identifying a systemic problem (with some egregious bad actors); others view him as having muddled the issues and assigning blame without enough in-depth analysis. One negative reviewer summed up his disappointment with the book this way: “What I got was a jeremiad against the doctors and pharmaceutical companies that was loosely based on a couple of research studies with very specific data that had little general application despite the author’s attempt to do so.” Ouch.

In spite of some loud criticism, Meier stays on the beat. He recently wrote an article with some interesting information; namely, that in the last two decades, the U.S. market for urine drug testing has more than doubled, to over two billion dollars annually.

The rise mirrors the growth in the prescribing and availability of opioid (morphine-like) prescription pain medication. Why so much money in urine drug testing?Liquid-Gold

Doctors use urine drug testing for at least two reasons:

  1. To assure “good behavior.” Many offices and clinics that prescribe narcotics seek to make sure that patients are not taking illicit (or non-prescribed) substances. Doing so can result in dismissal from such clinics for ‘aberrant behavior.’
  2. To assess adherence: If you prescribe narcotic pain medication, you want to be sure that your patient is actually taking the medication as prescribed. If I prescribe Oxycontin for someone but there’s no evidence of it in their system, how do I know they’re not selling it on the street (what’s known in the trade as diversion)?

All of that aside, shouldn’t we simply trust our patients when they tell us they’re in pain, and let the authorities handle the law enforcement side of things? No one likes to be swindled, but is it really the doctor’s role to patrol for potential criminal behavior?

I will say this. I know that I’ve had patients for whom I’ve prescribed opioids divert them. I would never do it knowingly. But the economy’s bad. Selling controlled prescription drugs is a source of income for people without employment or marketable skills. In the fancy world, it’s called arbitrage. If I’m lucky enough to have insurance (e.g. Medicaid) pay for all or 95% of my monthly narcotic prescription, then I can go out and sell the pills for cash. Easy money. Even if I pay full price at the pharmacy, I can still get a markup on the street.

I’d love to see conclusive research on how many of the patients who obtain chronic narcotic prescriptions divert them. We have estimates, but really no clear idea. I’m guessing it’s a much bigger problem than we know of or that anyone would care to admit.

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