Health Policy Critique
Urine Drug Screen Collection Policy
D’Ann Somerall
University of Alabama
School of Nursing
Doctorate of Nursing Practice
Paper submitted in partial fulfillment of requirements for NUR 790,
Health Policy and Politics.
September 14, 2009
Introduction
The policy to be critiqued is the urine drug screen (UDS) collection policy used at the Pain
Clinic at Cooper Green Mercy Hospital (CGMH) in Birmingham, AL. The clinic has a census of
approximately 900 patients with an average of fifteen new referrals each month. The primary
chief complaint for referral is low back pain. Secondary referrals include chronic neck pain,
fibromyalgia, complex pain syndrome and cancer related pain.
The most widely used method of monitoring illicit drug use and/or drug adherence in a pain
clinic setting, such as in the CGMH Pain Clinic setting, is the UDS. Patients, at initial
appointment to the Pain Clinic, sign an Opiate Agreement which outlines the plan for receiving
opiates as a part of the treatment plan. The Opiate Agreement explains that the patient will
submit a urine sample for a drug screen evaluation at each medication pick-up and/or
appointment.
The author of this paper became aware of the poor procedure for urine drug screen
collection from the following actual interaction with a patient (Personal experience, July, 2009).
Ms. A was found to be positive by UDS for methamphetamines (only prescribed Methadone).
The patient was called to the Pain Clinic for counseling and was given a warning for illicit drug
use. This was all explained to the patient who very calmly stated that she had been buying
urine from a “kid who goes to a Methadone Clinic” because he had promised her he would stay
clean. This patient paid the “kid” twenty-five dollars per sample. The patient stated that since
“you” didn’t monitor what she took into the bathroom, she just put the sample from her source in
her purse and poured it into the container once she arrived at the clinic.
Description of Policy
The above facts being known the author sought to examine the official policy established by
the clinic. The author found that there is no official policy for the collection of urine samples for
the Pain Clinic. A review of the eight year history of the clinic found a set of Policies and
Procedures which were initially formulated but were never submitted for formal review for
adoption.
The “unofficial” policy states, “A patient will submit a urine sample as deemed appropriate by
the health care provider.” (Policy and Procedures, 2001) The patient is verbally instructed that
the UDS provides not only monitoring for drug adherence and for illicit drug use, but can also
provide grounds for termination from the clinic. With such dire consequences contingent on the
results of the UDS, the author believes there should be an established policy in place.
Discussions with the Clinic Director regarding establishing a policy spearheaded the decision
to use the Urine Specimen Collection Guidelines set forth by the Department of Transportation
(DOT). These guidelines are detailed and specific and are updated on a consistent basis by the
DOT.
The following are guidelines outline the process for urine collection for prescription pick-up
from the Pain Clinic at CGMH:
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The patient signs a registration log at clerk’s window
The unit clerk informs, via phone, the LPN/MA that the patient has registered for
prescription pick-up
The LPN/MA calls the patient to a triage room where the patient presents a “blue
card” which states the co-pay information; staff collects co-pay if applicable (the
blue card is NOT a photo ID)
The staff retrieves urine cup and label, writes name of patient and patient’s
medical record number on label which is affixed to cup; zip lock bag and cup are
given to patient
The patient is directed to the hallway public bathroom where the toilet has no
blue dye, water and hand soap are available for hand washing
The patient exits bathroom after voiding and is directed to place cup with sample
in plastic bag and to deposit it in tub; the tub with all samples from morning are
taken to the lab prior to lunch break and the samples from the afternoon are
taken to the lab after the conclusion of patient appointments
o
The UDS analyzes for benzodiazepines, amphetamines, methamphetamines,
opiates, cocaine, THC and Methadone
Effects of Policy
The health care providers in the Pain Clinic use the results of the UDS to monitor adherence
to the medication treatment regimen and to determine if the patient is avoiding illicit drugs
which, in combination with the drugs prescribed by the providers in the Pain Clinic, could be
harmful to the patient. A small number of patients have had positive UDS’s that have caused
these patients to be discharged from the clinic. The most valuable benefit thus far has been to
monitor adherence to the treatment regimen as outlined.
Identification and Application of Model
The following are guidelines established by the Department of Transportation for quality UDS
collection (only the guidelines that can be used by the Pain Clinic are listed):
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A single toilet restroom with full length privacy door or a multi-stall restroom with
partial length doors are to be utilized (DOT, pg 4)
A source of water for washing hands is external to the restroom; if only source of
water is available in the restroom the patient may wash his or her hands and then
the water source is cut off
A bluing agent is instilled in the toilet, plus soap dispensers are secured to
alleviate adulteration of the sample
Patient presents an acceptable photo ID (driver’s license, military ID)
Actual Collection process:
Before each collection to deter potential tampering, adulteration, alteration or
substitution of the specimen
 Secure all water sources
 Water in tank and toilet has bluing agent instilled
 Secure areas and items (trash can, paper towel holder, under sink area)
 Only one collection at a time
 Presentation of photo identification
 Patient is asked to remove all unnecessary outer clothing and to leave
purse and other belongings with outer clothing (may safeguard items by
locking in a secured area)
 Patient is to empty pockets and display items to ensure no items are
present that could be used to adulterate the specimen
 Patient is directed to wash hands and dry – no further access to water
may be allowed
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Specimen collection device is given to patient who un-breaks the seal at
that time
Patient is directed to restroom for urination of at least 45 mls, told not to
flush toilet and to return specimen to staff
After staff have acquired specimen temperature (90 degrees to 100
degrees) and volume are measured and specimen is observed for
adulteration or substitution
Conclusions/Suggestions
The following are ideas for modifications to the guidelines provided by the DOT and the
present “unofficial guidelines” for the Pain Clinic Urine Collection. The DOT, even modified,
would ensure optimal accountability on the patient’s part for providing a true urine sample.
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The restroom used by the Pain Clinic is also used by the patients attending Physical
Therapy sessions and Psychiatry appointments. Thus, turning off the water supply
would inconvenience many patients not in the Pain Clinic, but using a bluing agent would
be an easy line of defense from using water from the toilet and tank and would be a very
cheap intervention.
Assessing the temperature of the urine sample immediately upon receipt of the sample
would provide an instant accountability measure.
Patient will be required to leave outer clothing and purses, satchels in triage room in a
locked cabinet. This simple step will alleviate samples being hidden in purses, etc.
Patient will present photo ID as well as blue card for identification.
The primary benefit of developing a written policy is to ensure consistency and quality of
care. By utilizing certain aspects of the DOT Guidelines in formulating collection guidelines fo r
the Pain Clinic the consistency and quality of care for the patients will be improved – and
improved care is what we, as health care providers, should all strive to obtain.
References
Urine Specimen Collection Guidelines. Department of Transportation, August 25, 2008,
http://transportation.ky.gov/transportationdelivery/Urine%20Collection%20Guidelines%20(Effecti
ve%20August%2025,%202008).pdf
Policies and Procedures for the Cooper Green Mercy Hospital Pain Clinic. (unofficial copy)
August, 2001.