Tuesday, September 18, 2007

"Gotcha" Medicine

I don't care if you do drugs. I don't care if you smoke marijuana. I don't care how many times you have been seen here in the last month for chest pain, or abdominal pain, or endometriosis. There is almost never a reason to order a urine drug screen. It almost never changes anything I do with the notable exception of cocaine and chest pain so please, nurses, don't come to me and ask me to order this $400 test so we can play detective. Besides the fact that the UDS is notoriously inaccurate and misses a host of intoxicants and many benzodiazepines it is not our job to catch people. In fact, this kind of thinking will burn your ass because while we all remember the story of the boy who cried wolf the point of that particular story is that one day there was a wolf.

I do order them for psychiatric admits but grind my teeth every time because it certainly won't change the fact that someone needs a psychiatric admission and I am left to wonder why I have to do the test here when the test can be ordered at the admitting facility...
but I have quit fighting.

It happened when I was in residency that an internist moonlighting as a detective found on a UDS that someone was using cocaine and this sleuth withheld pain medicines for the patient as a result. The patient signed out against medical advice and died the next day. Legally defensible? Probably. Ethical? No. Smart? No. Waste of money? Yes. Poetic justice? Certainly not for us to determine. Besides, and I don't say 'studies have shown' much, BUT, studies HAVE shown that the most accurate drug screen is the simple expedient of asking the patient if they use drugs.


  1. 20% false positives, 20% false negatives...just wow.

  2. wouldn't it be worse to withold pain meds (when indicated for a non med-seeking patient) to an addict because their friends would just sneak in street drugs anyways?

  3. I just don't understand this whole thing of nurses who not only believe every one in this world is a drug addict, but they also want to prove it. What I really don't understand is why the nurses of today seem to be the one's in charge more so than the doctor's.

  4. hey anonymous'... you need to read a book on the us'e of apos'trophe's.

  5. Hey 911 Doc:

    Hear hear.

    I have ordered two drug screens in my life. One was for a patient who had OD'd, but we were treating empirically anyhow.

    The other was for a guy who had got himself worked up that he was going to flunk his drugs screen at work the next day and lose his job. He told me what to test for.

    You can guess the result.