Psychiatry residents' and fellows' confidence and knowledge in interpreting urine drug testing results related to opioids

Drug Testing Interpretation in the Peripartum Setting: Results of Clinician Survey

OBJECTIVES

The objectives of this study were to (1) survey obstetrical and pediatric clinicians' experience, confidence, and training in maternal and neonatal drug testing interpretation; (2) determine their proficiency in drug test interpretation; and (3) assess predictors of correct interpretation.

METHODS

We conducted a cross-sectional survey of clinicians caring for pregnant people or newborns at an urban academic center. We assessed clinicians' demographic characteristics, experience, confidence, and prior training in interpretation of maternal and newborn drug tests. We assessed proficiency in interpreting drug tests using 11 clinical vignettes and categorized scores as poor (0-2), fair (3-5), and good (≥6) performance to facilitate data interpretation. We used descriptive statistics to summarize responses. Multinomial logistic regression was used to determine associations of clinician characteristics and score category (reference category: poor performance).

RESULTS

In total, 103 respondents completed the survey including 60 obstetrical clinicians (58.3%), 19 family medicine physicians (18.5%), 21 pediatric clinicians (20.4%), and 3 social workers (2.9%) (response rate, ~40%). The mean correct response was 4.1 (SD, 2.17; range, 0-11). Most respondent scores were fair (n = 47.6%), followed by good (n = 28.2%) and poor (n = 24.3%). Increased frequency, confidence, and training in interpreting maternal screening and confirmatory tests were associated with higher proficiency. Increased confidence and training in interpreting neonatal screening and confirmatory tests, but not frequency, were associated with higher proficiency.

CONCLUSIONS

Most clinicians demonstrated fair proficiency in interpreting drug tests. Predictors of proficiency were confidence and prior training for drug test interpretation, suggesting that educational interventions could improve proficiency.

Assessing knowledge gaps and educational needs in urine drug test interpretation among health care professionals

OBJECTIVES

Urine drug testing (UDT) is a critical tool used in medical, forensic, and occupational settings, but interpreting results can be challenging. We performed a study to assess the ability of health care professionals to interpret UDT results accurately.

METHODS

In total, 911 clinical and laboratory professionals in the United States and Canada responded to a survey with questions gauging expertise in UDT interpretation. Responses were analyzed to identify knowledge gaps.

RESULTS

Toxicologists and laboratory PhD scientists performed well, with means of 4.82 and 4.63 questions answered correctly (out of 6 possible), respectively. Physicians specializing in pathology, emergency medicine, primary care, and internal medicine, however, displayed concerning knowledge gaps, as did laboratorians with nondoctoral degrees. Experience and training correlated with interpretation accuracy. Identification of simulated compliance as well as understanding opioid exposure, metabolism, and immunoassay cross-reactivity were among the most clinically significant knowledge gaps. More than 30% of survey respondents indicated that they would seek UDT information from the internet or peers rather than clinical or laboratory experts.

CONCLUSIONS

The study highlighted the need for targeted education and better collaboration between clinical and laboratory experts and other health care professionals to ensure that when physicians order UDT, they can accurately interpret results and reduce harm.

Residents' Knowledge regarding Recreational Drug Screening Immunoassays at a Swiss Hospital Group

Introduction

In case of suspected acute recreational drug toxicity, immunoassays are commonly used as diagnostic tools. Although easy to handle, understanding of their limitations is necessary for a correct interpretation of the results. The aim of this project was to investigate residents' knowledge regarding drug screening immunoassays at a Swiss hospital group.

Methods

All residents of a large hospital group in Switzerland were invited by e-mail to participate in an anonymous survey. Following ten multiple choice questions on drug screening tests, the participants were also asked about their demographics, whether they used drug screening tests on a regular basis, and how confident they felt in their ability to interpret test results.

Results

The ten knowledge questions were answered by 110 of the 1026 residents (11%). Among the 108 participants with available demographics, 90% were 25-35 years old, 63% were female, and 70% were at least in their 4th year of residency. The median score of correct answers was 4 out of 10 (range 0-7) and in 50% of the questions, the correct answer was the most frequently selected response. No significant differences in the knowledge scores were found based on the training, confidence level, or the frequency of drug tests used in daily work.

Conclusion

This survey revealed widespread knowledge gaps among residents regarding the interpretation of immunoassay-based drug test results. These findings can be used to implement educational measures on this topic and might provide a basis for targeted information on common pitfalls to be included in laboratory reports.

The North American opioid epidemic: opportunities and challenges for clinical laboratories

Since 1999, the opioid epidemic in North America has resulted in over 1 million deaths, and it continues to escalate despite numerous efforts in various arenas to combat the upward trend. Clinical laboratories provide drug testing to support practices such as emergency medicine, substance use disorder treatment, and pain management; increasingly, these laboratories are collaborating in novel partnerships including drug-checking services (DCS) and multidisciplinary treatment teams. This review examines drug testing related to management of licit and illicit opioid use, new technologies and test strategies employed by clinical laboratories, barriers hindering laboratory response to the opioid epidemic, and areas for improvement and standardization within drug testing. Literature search terms included combinations of "opioid," "opiate," "fentanyl," "laboratory," "epidemic," "crisis," "mass spectrometry," "immunoassay," "drug screen," "drug test," "guidelines," plus review of PubMed "similar articles" and references within publications. While immunoassay (IA) and point-of-care (POC) test options for synthetic opioids are increasingly available, mass spectrometry (MS) platforms offer the greatest flexibility and sensitivity for detecting novel, potent opioids. Previously reserved as a second-tier application in most drug test algorithms, MS assays are gaining a larger role in initial screening for specific patients and DCS. However, there are substantial differences among laboratories in terms of updating test menus, algorithms, and technologies to meet changing clinical needs. While some clinical laboratories lack the resources and expertise to implement MS, many are also slow to adopt available IA and POC tests for newer opioids such as fentanyl. MS-based testing also presents challenges, including gaps in available guidance for assay validation and ongoing performance assessment that contribute to a dramatic lack of standardization among laboratories. We identify opportunities for improvement in laboratory operations, reporting, and interpretation of drug test results, including laboratorian and provider education and laboratory-focused guidelines. We also highlight the need for collaboration with providers, assay and instrument manufacturers, and national organizations to increase the effectiveness of clinical laboratory and provider efforts in preventing morbidity and mortality associated with opioid use and misuse.

Assessing pharmacy students' knowledge and perceptions of urine drug testing following a pharmacy skills laboratory

INTRODUCTION

Urine drug tests (UDTs) are commonly used in the healthcare setting to monitor adherence, abuse, and diversion of controlled substances. The goal of our study was to assess the knowledge and perceptions of third-year pharmacy students on UDTs following an educational experience.

METHODS

Third-year pharmacy students completed pre- and post-questionnaires following a skills laboratory focused on the use of UDTs in clinical settings. The 34-item questionnaires consisted of three domains: demographics, knowledge regarding UDTs, and personal perceptions of UDTs. A pre-lab teaching podcast was assigned prior to the laboratory session, and two clinical cases were discussed during the live UDT segment. Descriptive statistics were used to assess demographics, and changes in knowledge and perceptions of UDTs were evaluated using chi-square and Mann-Whitney U, respectively, with an a priori alpha of 0.05.

RESULTS

One hundred twenty students were included in the analysis. Students in the laboratory were predominately female (n = 72, 60%), Caucasian (n = 84, 70%), and had no prior training with UDTs (n = 104, 86.7%). Student knowledge of UDT interpretation significantly increased from 57% to 71% (four and five correct answers out of seven, respectively). Confidence interpreting UDTs and answering questions related to UDTs also increased significantly. Students felt the laboratory experience was valuable, with 84.2% agreeing or strongly agreeing.

CONCLUSIONS

Educational programming focused on UDTs improves student confidence interpreting results and knowledge related to the use of UDTs.

Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results

BACKGROUND

Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers' ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) results, has not been widely studied.

OBJECTIVE

To examine whether providers correctly interpret, document, and communicate LC-MS/MS UDT results.

DESIGN

This is a retrospective chart review of 160 UDT results (80 aberrant; 80 non-aberrant) between August 2017 and February 2018 from 5 ambulatory clinics (3 primary care, 1 oncology, 1 pain management). Aberrant results were classified into one or more of the following categories: illicit drug use, simulated compliance, not taking prescribed medication, and taking a medication not prescribed. Accurate result interpretation was defined as concordance between the provider's documented interpretation and an expert laboratory toxicologist's interpretation. Outcome measures were concordance between provider and laboratory interpretation of UDT results, documentation of UDT results, results acknowledgement in the electronic health record, communication of results to the patient, and rate of prescription refills.

KEY RESULTS

Aberrant results were most frequently due to illicit drug use. Overall, only 88 of the 160 (55%) had any documented provider interpretations of which 25/88 (28%) were discordant with the laboratory toxicologist's interpretation. Thirty-six of the 160 (23%) documented communication of the results to the patient. Communicating results was more likely to be documented if the results were aberrant compared with non-aberrant (33/80 [41%] vs. 3/80 [4%], p < 0.001). In all cases where provider interpretations were discordant with the laboratory interpretation, prescriptions were refilled.

CONCLUSIONS

Erroneous provider interpretation of UDT results, infrequent documentation of interpretation, lack of communication of results to patients, and prescription refills despite inaccurate interpretations are common. Expert assistance with urine toxicology interpretations may be needed to improve provider accuracy when interpreting toxicology results.