The major goals of exposure testing in the chronic pain or addiction management setting are to verify that a patient has recently taken the drug(s) prescribed to him or her, and to detect use of nonprescribed drugs. Random urine drug testing, used in combination with other tools for evaluating patient behavior, is thought to reduce the likelihood of drug misuse and thereby promote patient safety and efficacy. Urine drug tests are recommended by the 2016 Guideline for Prescribing Opioids for Chronic Pain that was published by the Centers for Disease Control and Prevention (1), as well as many professional associations, including the American Pain Society and the American Association of Pain Management. That said, no test is perfect—no single drug test can detect all drugs—and detection of drugs does not equate to adherence with therapy. Some laboratories have applied forensic drug-testing principles and practices from the federal workplace drug-testing program, managed by the Substance Abuse and Mental Health Services Administration (SAMHSA)3, to urine drug testing performed in a clinical setting. This makes sense because the SAMHSA program mandates content of drug tests and cutoffs, i.e., the concentration thresholds used to differentiate positive from negative results. However, experience has demonstrated that the drugs of interest to chronic pain or addiction management, …
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