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
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Urine drug testing (UDT) can help identify misuse or diversion of opioid medications among patients with chronic pain. However, misinterpreting results can lead to false reassurance or erroneous conclusions about drug use.
To examine the relationship between resident physicians’ knowledge about UDT interpretation and confidence in their ability to interpret UDT results.
Internal medicine residents in a university health system in the Bronx, from 2010 to 2011.
We assessed knowledge using a 7-item scale (UDT knowledge score), and confidence in UDT interpretation using a single statement (“I feel confident in my ability to interpret the results of urine drug tests”). We conducted chi-square tests, t-tests, and logistic regression to determine the association between knowledge and confidence, and in exploratory analyses to examine whether resident characteristics (gender, training level, and UDT use) moderated the relationship between knowledge and confidence.
Among 99 residents, the mean UDT knowledge score was 3.0 out of 7 (SD 1.2). Although 55 (56 %) of residents felt confident in their ability to interpret UDT results, 40 (73 %) of confident residents had a knowledge score of 3 or lower. Knowledge score was not associated with confidence among the full sample or when stratified by training level or UDT use. The association between knowledge and confidence differed significantly by gender (interaction term p < 0.01). Adjusting for training level and UDT use, knowledge was positively associated with confidence among females (AOR 1.79, 95 % CI: 1.06, 3.30), and negatively associated with confidence among males (AOR 0.47, 95 % CI: 0.23, 0.98).
Despite poor knowledge about UDT interpretation, most resident physicians felt confident in their ability to interpret UDT results. Gender differences warrant further exploration, but even confident physicians who use UDT should evaluate their proficiency in interpreting UDT results. Educational initiatives should emphasize the complexities of UDT interpretation.
- Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment Episode Data Set (TEDS) Highlights-- 2006 National Admissions to Substance Abuse Treatment Services. OAS Series #S-40, DHHS Publication No. (SMA) 08–4313, Rockville, MD, 2007; http://www.samhsa.gov/data/TEDS2k6highlights/TOC.htm. Accessed 10 July 2012.
- Paulozzi, LJ, Budnitz, DS, Xi, Y (2006) Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 15: pp. 618-627 CrossRef
- Centers for Disease Control and Prevention. Vital Signs: Overdoses of Prescription Opioid Pain Relievers-- United States, 1999–2008. In: MMWR Morb Mortal Wkly Rep. 4 Nov 2011 ed:1487–92.
- Chou, R, Fanciullo, GJ, Fine, PG (2009) Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10: pp. 113-130 CrossRef
- Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT, 2009; http://www.dopl.utah.gov/licensing/forms/OpioidGuidlines.pdf Accessed 10 July 2012.
- Trescot, AM, Helm, S, Hansen, H (2008) Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines. Pain Physician 11: pp. S5-S62
- Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain. 2010; http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf Accessed 10 July 2012.
- McLellan, AT, Turner, B (2008) Prescription opioids, overdose deaths, and physician responsibility. JAMA 300: pp. 2672-2673 CrossRef
- Atluri, S, Sudarshan, G (2003) Evaluation of abnormal urine drug screens among patients with chronic non-malignant pain treated with opioids. Pain Physician 6: pp. 407-409
- Fishbain, DA, Cutler, RB, Rosomoff, HL, Rosomoff, RS (1999) Validity of self-reported drug use in chronic pain patients. Clin J Pain 15: pp. 184-191 CrossRef
- Katz, N, Fanciullo, GJ (2002) Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain 18: pp. S76-S82 CrossRef
- Berndt, S, Maier, C, Schütz, H-W (1993) Polymedication and medication compliance in patients with chronic non-malignant pain. Pain 52: pp. 331-339 CrossRef
- Schuckman, H, Hazelett, S, Powell, C, Steer, S (2008) A validation of self-reported substance use with biochemical testing among patients presenting to the emergency department seeking treatment for backache, headache, and toothache. Subst Use Misuse 43: pp. 589-595 CrossRef
- Katz, NP, Sherburne, S, Beach, M (2003) Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 97: pp. 1097-1102 CrossRef
- Starrels, JL, Becker, WC, Alford, DP, Kapoor, A, Williams, AR, Turner, BJ (2010) Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med 152: pp. 712-720
- Heit, HA, Gourlay, DL (2004) Urine drug testing in pain medicine. J Pain Symptom Manag 27: pp. 260-267 CrossRef
- Gilbert JW, Wheeler GR, Mick GE, et al. Importance of urine drug testing in the treatment of chronic noncancer pain: implications of recent medicare policy changes in kentucky. Pain physician. 13:167–86.
- Reisfield, GM, Salazar, E, Bertholf, RL (2007) Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci 37: pp. 301-314
- Moeller, KE, Lee, KC, Kissack, JC (2008) Urine drug screening: practical guide for clinicians. Mayo Clin Proc 83: pp. 66-76 CrossRef
- Tenore, PL (2010) Advanced urine toxicology testing. J Addict Dis 29: pp. 436-448 CrossRef
- Melanson, SE, Kredlow, MI, Jarolim, P, Melanson, SEF, Kredlow, MI, Jarolim, P (2009) Analysis and interpretation of drug testing results from patients on chronic pain therapy: a clinical laboratory perspective. Clin Chem Lab Med 47: pp. 971-976 CrossRef
- Reisfield GM, Webb FJ, Bertholf RL, Sloan PA, Wilson GR. Family physicians' proficiency in urine drug test interpretation. J Opioid Manag. 2007;3.
- Levy, S, Harris, SK, Sherritt, L, Angulo, M, Knight, JR (2006) Drug testing of adolescents in ambulatory medicine: physician practices and knowledge. Arch Pediatr Adolesc Med 160: pp. 146-150 CrossRef
- Duffy, FD, Holmboe, ES (2006) Self-assessment in lifelong learning and improving performance in practice: physician know thyself. JAMA 296: pp. 1137-1139 CrossRef
- Davis, DA, Mazmanian, PE, Fordis, M, Harrison, R, Thorpe, KE, Perrier, L (2006) Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 296: pp. 1094-1102 CrossRef
- Blanch, DC, Hall, JA, Roter, DL, Frankel, RM (2008) Medical student gender and issues of confidence. Patient Educ Couns 72: pp. 374-381 CrossRef
- Lundeberg MA. Highly Confident, but Wrong: Gender Differences and Similarities in Confidence Judgments. Annual Meeting of the American Educational Research Association. San Francisco, CA, 1992; http://eric.ed.gov/PDFS/ED347899.pdf Accessed 10 July 2012.
- Nomura K, Yano E, Fukui T. Gender differences in clinical confidence: a nationwide survey of resident physicians in Japan. Acad Med. 85:647–53.
- Harris, JM, Fulginiti, JV, Gordon, PR (2008) KnowPain-50: a tool for assessing physician pain management education. Pain Med 9: pp. 542-554 CrossRef
- Yanni, LM, Weaver, MF, Johnson, BA, Morgan, LA, Harrington, SE, Ketchum, JM (2008) Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic. J Opioid Manag 4: pp. 201-211 CrossRef
- Reisfield, GM (2007) Urine drug test interpretation: what do physicians know?. J Opioid Manag 3: pp. 80-86
- Berner, ES, Graber, ML (2008) Overconfidence as a cause of diagnostic error in medicine. Am J Med 121: pp. S2-S23 CrossRef
- Christo, PJ, Manchikanti, L, Ruan, X (2011) Urine drug testing in chronic pain. Pain Physician 14: pp. 123-143
- Cone, EJ, Caplan, YH, Cone, EJ, Caplan, YH (2009) Urine toxicology testing in chronic pain management. Postgraduate Med 121: pp. 91-102 CrossRef
- Isaacson, JH, Fleming, M, Kraus, M, Kahn, R, Mundt, M (2000) A national survey of training in substance use disorders in residency programs. J Stud Alcohol 61: pp. 912-915
- Fleming, MF, Manwell, LB, Kraus, M, Isaacson, JH, Kahn, R, Stauffacher, EA (1999) Who teaches residents about the prevention and treatment of substance use disorders? A national survey. J Fam Pract 48: pp. 725-729
- Miller, NS, Sheppard, LM, Colenda, CC, Magen, J (2001) Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med 76: pp. 410-418 CrossRef
- Lynch, JR, Schmale, GA, Schaad, DC, Leopold, SS (2006) Important demographic variables impact the musculoskeletal knowledge and confidence of academic primary care physicians. J Bone Joint Surg Am 88: pp. 1589-1595 CrossRef
- Haywood, BL, Porter, SL, Grana, WA (2006) Assessment of musculoskeletal knowledge in primary care residents. Am J Orthop (Belle Mead NJ) 35: pp. 273-275
- Pergolizzi, J, Pappagallo, M, Stauffer, J (2010) The role of urine drug testing for patients on opioid therapy. Pain Pract 10: pp. 497-507 CrossRef
- Bornstein, BH, Emler, AC (2001) Rationality in medical decision making: a review of the literature on doctors' decision-making biases. J Eval Clin Pract 7: pp. 97-107 CrossRef
- Shults TF. The Medical Review Officer Handbook, Ninth Edition. Research Triangle Park, NC: Quadrangle Research, LLC; 2009.
- 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
Journal of General Internal Medicine
Volume 27, Issue 11 , pp 1521-1527
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- urine drug testing
- chronic pain
- opioid medications
- physician self-assessment
- Industry Sectors
- Author Affiliations
- 1. General Internal Medicine, Albert Einstein College of Medicine, 111 E. 210 St, Bronx, NY, 10467, USA
- 2. Montefiore Medical Center, Bronx, NY, USA