Open Access Open Access  Restricted Access Subscription or Fee Access

Provider reasons for discontinuing long-term opioid therapy following aberrant urine drug tests differ based on the type of substance identified

Jessica J. Wyse, PhD, Benjamin J. Morasco, PhD, Steven K. Dobscha, MD, Michael I. Demidenko, BS, Thomas H. A. Meath, MPH, Travis I. Lovejoy, PhD, MPH


Objective: Urine drug testing (UDT) is increasingly performed as a means of identifying aberrant behavior that may be grounds for discontinuation of long-term opioid therapy (LTOT). Little is known, however, about the ways in which positive UDT results may differentially inform decisions to discontinue LTOT based on the type of substance for which the UDT screened positive. The aim of this study was to examine the likelihood of clinician-initiated discontinuation of LTOT attributed to positive UDT results across three discrete categories of substances: (1) cannabis, (2) alcohol or illicit substances (excluding cannabis), and (3) controlled prescription medications that were not prescribed.

Design: This retrospective study utilized the US Department of Veterans Affairs (VA) Health Care System. Corporate Data Warehouse to assemble a sample of 600 patients with substance use disorders and matched controls who were discontinued from LTOT in 2012. Comprehensive manual medical record review identified UDT results in the year prior to discontinuation and reason(s) for discontinuation.

Patients, Participants: Patients with one or more UDTs positive for a single substance (N = 185) comprised the study sample.

Main Outcome Measure(s): Likelihood of clinician-initiated discontinuation attributed to a positive UDT across the three categories.

Results: Patients with one or more UDTs positive for cannabis were more likely to be discontinued from opioid therapy as a result of the positive UDT compared to those with one or more UDTs positive for nonprescribed prescription medication (adjusted odds ratio [OR] = 18.05, 95% CI = 7.29-44.66). Similarly, patients with UDTs positive for alcohol or illicit substances were more likely to be discontinued for the positive UDTs relative to patients who tested positive for nonprescribed prescription medications (adjusted OR = 13.10, 95% CI = 4.81-35.68). No difference in UDT-related discontinuation decisions was evident between patients with UDTs positive for alcohol/illicit substances versus cannabis (adjusted OR = 1.47, 95% CI = 0.57-3.77).

Conclusions: High odds of UDT-related discontinuation were found in patients who tested positive for cannabis, alcohol, or illicit substances, relative to nonprescribed prescription medications.


urine drug test, long-term opioid therapy, substance misuse, substance abuse, opioid discontinuation

Full Text:



Chou R, Turner JA, Devine EB, et al.: The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015; 162(4): 276-286.

Baldini A, Von Korff M, Lin EH: A review of potential adverse effects of long-term opioid therapy: A practitioner's guide. Prim Care Companion CNS Disord. 2012; 14(3). doi:10.4088/PCC.11m01326.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152(2): 85-92.

Ray WA, Chung CP, Murray KT, et al.: Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016; 315(22): 2415-2423.

Centers for Disease Control and Prevention (CDC): Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR. 2011; 60(43): 1487-1492.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645.

The Opioid Therapy for Chronic Pain Work Group: VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Washington, DC: U.S. Department of Veterans Affairs/U.S. Department of Defense, 2017.

Chou R, Fanciullo GP, 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: 113-130.

Coffin PO, Galea S, Ahern J, et al.: Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York city, 1990–98. Addiction. 2003; 98(6): 739-747.

Park TW, Saitz R, Ganoczy D, et al.: Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: Case-cohort study. BMJ (Clinical Research Ed.). 2015; 350: h2698.

Sun EC, Dixit A, Humphreys K, et al.: Association between concurrent use of prescription opioids and benzodiazepines and overdose: Retrospective analysis. BMJ (Clinical Research Ed.). 2017; 356: j760.

White JM, Irvine RJ: Mechanisms of fatal opioid overdose. Addiction. 1999; 94(7): 961-972.

Martin BC, Fan M, Edlund MJ, et al.: Long-term chronic opioid therapy discontinuation rates from the TROUP study. J General Intern Med. 2011; 26(12): 1450-1457.

Vanderlip ER, Sullivan MD, Edlund MJ, et al.: National study of discontinuation of long-term opioid therapy among veterans. Pain. 2014; 155(12): 2673-2679.

Lovejoy TI, Morasco BJ, Demidenko MI, et al.: Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017; 158(3): 526-534.

Demidenko MI, Dobscha SK, Morasco BJ, et al.: Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017; 47: 29-35.

Nugent SM, Dobscha SK, Morasco BJ, et al.: Substance use disorder treatment following clinician-initiated discontinuation of long-term opioid therapy resulting from an aberrant urine drug test. J Gen Intern Med. 2017; 32(10): 1076-1082.

Frank JW, Lovejoy TI, Becker WC, et al.: Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: A systematic review. Ann Intern Med. 2017; 167(3): 181-191.

National Conference of State Legislatures: Marijuana overview. Available at Accessed August 9, 2017.

Nugent SM, Morasco BJ, O'Neil ME, et al.: The effects of cannabis among adults with chronic pain and an overview of general harms: A systematic review. Ann Intern Med.. 2017; 167(5): 319-331.

Bachhuber MA, Saloner B, Cunningham CO, et al.: Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014; 174(10): 1668-1673.

Turner BJ, Liang Y: Drug overdose in a retrospective cohort with non-cancer pain treated with opioids, antidepressants, and/or sedative-hypnotics: Interactions with mental health disorders. J Gen Intern Med. 2015; 30(8): 1081-1096.

Bohnert AS, Ilgen MA, Ignacio RV, et al.: Risk of death from accidental overdose associated with psychiatric and substance use disorders. AJP. 2012; 169(1): 64-70.

Morrill R, Cromartie J, Hart G: Metropolitan, urban, and rural commuting areas: Toward a better depiction of the United States settlement system. Urban Geogr. 1999; 20(8): 727-748.

Elixhauser A, Steiner C, Harris DR, et al.: Comorbidity measures for use with administrative data. Med Care. 1998; 36(1): 8-27.

Passik SD, Kirsh KL, Whitcomb LA, et al.: Pain clinicians' rankings of aberrant drug-taking behaviors. J Pain Palliat Care Pharmacother, 2002; 16(4): 39-49.

Pew Research Center: Late August 2016 RDD nonresponse survey. Available at Accessed June 30, 2017.

Lau N, Sales P, Averill S, et al.: A safer alternative: Cannabis substitution as harm reduction. Drug Alcohol Rev. 2015; 34(6): 654-659.

Reisfield GM, Bertholf R, Barkin RL, et al.: Urine drug test interpretation: What do physicians know? J Opioid Manag. 2007; 3(2): 80-86.

Reisfield GM, Webb FJ, Bertholf RL, et al.: Family physicians’ proficiency in urine drug test interpretation. J Opioid Manag. 2007; 3(6): 333-337.

Starrels JL, Fox AD, Kunins HV, et al.: They don't know what they don't know: Internal medicine residents’ knowledge and confidence in urine drug test interpretation for patients with chronic pain. J Gen Intern Med. 2012; 27: 1521-1527.

Haymond S, Nagpal G, Heiman H: Urine drug screens to monitor opioid use for managing chronic pain. JAMA. 2017; 318(11): 1061–1062.

Moeller KE, Lee KC, Kissack JC: Urine drug screening: Practical guide for clinicians. Mayo Clin Proc. 2008; 83(1): 66-76.

Morasco BJ, Krebs EE, Cavanagh R, et al.: Treatment changes following aberrant urine drug test results for patients prescribed chronic opioid therapy. J Opioid Manag. 2015; 11(1): 45-51.

Krebs EE, Bair MJ, Carey TS, et al.: Documentation of pain care processes does not accurately reflect pain management delivered in primary care. J Gen Intern Med. 2010; 25(3): 194-199.



  • There are currently no refbacks.