Journal of General Internal Medicine

, Volume 27, Issue 11, pp 1521–1527 | Cite as

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

  • Joanna L. Starrels
  • Aaron D. Fox
  • Hillary V. Kunins
  • Chinazo O. Cunningham
Original Research

ABSTRACT

BACKGROUND

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.

OBJECTIVE

To examine the relationship between resident physicians’ knowledge about UDT interpretation and confidence in their ability to interpret UDT results.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Internal medicine residents in a university health system in the Bronx, from 2010 to 2011.

MAIN MEASURES

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.

KEY RESULTS

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).

CONCLUSIONS

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.

KEY WORDS

urine drug testing chronic pain opioid medications physician self-assessment 

REFERENCES

  1. 1.
    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.
  2. 2.
    Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618–27.PubMedCrossRefGoogle Scholar
  3. 3.
    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.Google Scholar
  4. 4.
    Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113–30.PubMedCrossRefGoogle Scholar
  5. 5.
    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.
  6. 6.
    Trescot AM, Helm S, Hansen H, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians' (ASIPP) Guidelines. Pain Physician. 2008;11:S5–62.PubMedGoogle Scholar
  7. 7.
    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.
  8. 8.
    McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility. JAMA. 2008;300:2672–3.PubMedCrossRefGoogle Scholar
  9. 9.
    Atluri S, Sudarshan G. Evaluation of abnormal urine drug screens among patients with chronic non-malignant pain treated with opioids. Pain Physician. 2003;6:407–9.PubMedGoogle Scholar
  10. 10.
    Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of self-reported drug use in chronic pain patients. Clin J Pain. 1999;15:184–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002;18:S76–82.PubMedCrossRefGoogle Scholar
  12. 12.
    Berndt S, Maier C, Schütz H-W. Polymedication and medication compliance in patients with chronic non-malignant pain. Pain. 1993;52:331–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Schuckman H, Hazelett S, Powell C, Steer S. 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. 2008;43:589–95.PubMedCrossRefGoogle Scholar
  14. 14.
    Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1097–102.PubMedCrossRefGoogle Scholar
  15. 15.
    Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712–20.PubMedGoogle Scholar
  16. 16.
    Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manag. 2004;27:260–7.CrossRefGoogle Scholar
  17. 17.
    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.Google Scholar
  18. 18.
    Reisfield GM, Salazar E, Bertholf RL. Rational use and interpretation of urine drug testing in chronic opioid therapy. Ann Clin Lab Sci. 2007;37:301–14.PubMedGoogle Scholar
  19. 19.
    Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83:66–76.PubMedCrossRefGoogle Scholar
  20. 20.
    Tenore PL. Advanced urine toxicology testing. J Addict Dis. 2010;29:436–48.PubMedCrossRefGoogle Scholar
  21. 21.
    Melanson SE, Kredlow MI, Jarolim P, Melanson SEF, Kredlow MI, Jarolim P. Analysis and interpretation of drug testing results from patients on chronic pain therapy: a clinical laboratory perspective. Clin Chem Lab Med. 2009;47:971–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Reisfield GM, Webb FJ, Bertholf RL, Sloan PA, Wilson GR. Family physicians' proficiency in urine drug test interpretation. J Opioid Manag. 2007;3.Google Scholar
  23. 23.
    Levy S, Harris SK, Sherritt L, Angulo M, Knight JR. Drug testing of adolescents in ambulatory medicine: physician practices and knowledge. Arch Pediatr Adolesc Med. 2006;160:146–50.PubMedCrossRefGoogle Scholar
  24. 24.
    Duffy FD, Holmboe ES. Self-assessment in lifelong learning and improving performance in practice: physician know thyself. JAMA. 2006;296:1137–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296:1094–102.PubMedCrossRefGoogle Scholar
  26. 26.
    Blanch DC, Hall JA, Roter DL, Frankel RM. Medical student gender and issues of confidence. Patient Educ Couns. 2008;72:374–81.PubMedCrossRefGoogle Scholar
  27. 27.
    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.
  28. 28.
    Nomura K, Yano E, Fukui T. Gender differences in clinical confidence: a nationwide survey of resident physicians in Japan. Acad Med. 85:647–53.Google Scholar
  29. 29.
    Harris JM Jr, Fulginiti JV, Gordon PR, et al. KnowPain-50: a tool for assessing physician pain management education. Pain Med. 2008;9:542–54.PubMedCrossRefGoogle Scholar
  30. 30.
    Yanni LM, Weaver MF, Johnson BA, Morgan LA, Harrington SE, Ketchum JM. Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic. J Opioid Manag. 2008;4:201–11.PubMedCrossRefGoogle Scholar
  31. 31.
    Reisfield GM. Urine drug test interpretation: what do physicians know? J Opioid Manag. 2007;3:80–6.PubMedGoogle Scholar
  32. 32.
    Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2–23.PubMedCrossRefGoogle Scholar
  33. 33.
    Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123–43.PubMedGoogle Scholar
  34. 34.
    Cone EJ, Caplan YH, Cone EJ, Caplan YH. Urine toxicology testing in chronic pain management. Postgraduate Med. 2009;121:91–102.CrossRefGoogle Scholar
  35. 35.
    Isaacson JH, Fleming M, Kraus M, Kahn R, Mundt M. A national survey of training in substance use disorders in residency programs. J Stud Alcohol. 2000;61:912–5.PubMedGoogle Scholar
  36. 36.
    Fleming MF, Manwell LB, Kraus M, Isaacson JH, Kahn R, Stauffacher EA. Who teaches residents about the prevention and treatment of substance use disorders? A national survey. J Fam Pract. 1999;48:725–9.PubMedGoogle Scholar
  37. 37.
    Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Lynch JR, Schmale GA, Schaad DC, Leopold SS. Important demographic variables impact the musculoskeletal knowledge and confidence of academic primary care physicians. J Bone Joint Surg Am. 2006;88:1589–95.PubMedCrossRefGoogle Scholar
  39. 39.
    Haywood BL, Porter SL, Grana WA. Assessment of musculoskeletal knowledge in primary care residents. Am J Orthop (Belle Mead NJ). 2006;35:273–5.Google Scholar
  40. 40.
    Pergolizzi J, Pappagallo M, Stauffer J, et al. The role of urine drug testing for patients on opioid therapy. Pain Pract. 2010;10:497–507.PubMedCrossRefGoogle Scholar
  41. 41.
    Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors' decision-making biases. J Eval Clin Pract. 2001;7:97–107.PubMedCrossRefGoogle Scholar
  42. 42.
    Shults TF. The Medical Review Officer Handbook, Ninth Edition. Research Triangle Park, NC: Quadrangle Research, LLC; 2009.Google Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Joanna L. Starrels
    • 1
    • 2
  • Aaron D. Fox
    • 1
    • 2
  • Hillary V. Kunins
    • 1
    • 2
  • Chinazo O. Cunningham
    • 1
    • 2
  1. 1.General Internal MedicineAlbert Einstein College of MedicineBronxUSA
  2. 2.Montefiore Medical CenterBronxUSA

Personalised recommendations