This case raises several interesting questions about the clinical role of urine drug testing. First, it is important to distinguish between clinical, patient-centered drug testing, which is done for the patient with informed consent, and regulated or forensic drug testing, which is rarely performed in the best interests of the patient. Clearly, the testing strategy is different in these 2 situations.
This case discussion addresses the all too familiar challenges of end-of-life care that come to bear on the case of a young woman with end-stage cervical cancer. Although her case history is incomplete, it is clear that she had been on an escalating schedule of controlled- and immediate-release morphine to control pain. The reason for conducting the drug test is unclear, however, and traces of hydromorphone in the urine sample appear to conflict with the palliative treatment plan in place.
The presence of unprescribed hydromorphone in the patient’s urine may well have created some concern for her treatment team. The differential diagnosis that may account for such results includes medication error, interpatient medication diversion, and illicit drug smuggling by family or friends who believe they are assisting their dying loved one. Although the authors are likely correct in their interpretation of this finding as a minor metabolite of morphine, an occurrence first reported by Cone et al. in 2006 (1), the authors also raise important questions about the ethical challenges of drug testing in general and testing at the end of life in particular.
Unfortunately, a lack of information about the patient’s personal and family history precludes an assessment of risk of drug misuse and addiction. Even in the context of palliative care these issues remain important. A “universal precautions” approach to risk management may have answered many of these questions (2). For example, a drug misuse history, particularly involving drugs in the opioid class, would have made the interpretation of the urine drug testing results more challenging. It is important to remember that drug misuse and addiction can and do occur in the palliative care setting, even in the relatively controlled context of a hospice. Although such behavior may pose ethical challenges regarding the use of controlled substances, even at the end of life, these issues are often overlooked.
Had the case involved chronic noncancer pain, this urine drug testing result might well have led to discontinuation of opioid medication at best or discharge of the patient from the practice, actions largely based on a failure to appreciate basic opioid metabolic pathways. The revelation that a minor metabolic pathway may have accounted for the presence of trace amounts of hydromorphone could be discerned only through a careful examination of the clinical context, thus illustrating the importance of a patient-centered, team approach to problem solving. We would encourage readers to approach urine drug testing in a patient-centered fashion (3).
Author Contributions: All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.
Authors’ Disclosures of Potential Conflicts of Interest: Upon manuscript submission, all authors completed the Disclosures of Potential Conflict of Interest form. Potential conflicts of interest:
Employment or Leadership: None declared.
Consultant or Advisory Role: D. Gourlay, Pharmacofor; H.A. Heit, Purdue Pharma, Abbott Laboratories, King Pharmaceuticals, Ortho-McNeil-Jansen, Cephalon, and Endo Pharmaceuticals.
Stock Ownership: None declared.
Honoraria: D. Gourlay, King Pharmaceuticals, Cephalon, and Purdue; H.A. Heit, Purdue Pharma, Abbott Laboratories, King Pharmaceuticals, Ortho-McNeil-Jansen, and Cephalon.
Research Funding: None declared.
Expert Testimony: None declared.
Role of Sponsor: The funding organizations played no role in the design of study, choice of enrolled patients, review and interpretation of data, or preparation or approval of manuscript.
- © 2009 The American Association for Clinical Chemistry