Is it normal for psychiatrists to require urine tests while taking Adderall?
October 20, 2012 12:35 PM   Subscribe

Is it standard operating procedure for psychiatrists to give urine tests while using Adderall to treat ADHD?

My therapist recently referred me to to a psychiatric nurse to get evaluated for ADHD. The nurse administered the evaluation and, seeing that all signs pointed to "bloody likely," gave me a prescription for Adderall.

As she was giving me the prescription, she warned me that I will need to have my urine tested periodically at a lab, and that she would be the only one to see the results. I was initially very anxious, as I have never submitted to a urine test in my life, but she explained that periodical urinalysis is part of the regulations for prescribing Schedule II drugs. I don't believe her, as post-facto googling turned up nothing. I would prefer not to have my pee peered at if I can avoid it.

Are periodical urine tests while on a Schedule II drug required by law, or would I be able to find another psychiatric professional who would not require them?

I am in Rhode Island, if local regulations make a difference.
posted by anonymous to Health & Fitness (27 answers total) 2 users marked this as a favorite
Maybe in Rhode Island - definitely not in my state. I've gotten several Schedule II drugs prescribed over the last 15 years, and have been on ADHD meds (Vyvanse, not Adderall) for over a year. No urinalysis, no blood tests.

I have had blood tests for other things - carbomazepine and Lithium are both ones you have to be tested for - but that's for determining whether you've reached therapeutic levels.

I've also never, ever been told I can't see my own results, or that they can somehow magically be kept from other medical providers. My insurance company keeps track of all the test results they've paid for (I can look them up on the website, and I didn't sign up for anything special.)

The only urinalysis I have had that I'm reasonably sure has stayed with the testing agency was the stuff done for work (safety/pre-employment testing.) The reports they send to my employer just say "RESULTS NEGATIVE" or "RESULTS POSITIVE." I self-report all of my psych meds when they collect the samples, and they note it somehow or other, such that it never shows up as anything other than "RESULTS NEGATIVE" on my employer's report.

I'd call another area clinic and see if they do urinalysis, personally. It'd bug me enough that it'd be worth it. I find urinalysis to be invasive and I'd feel really disrespected by a doctor who behaved that way.
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 12:48 PM on October 20, 2012

I am on a (different) schedule II drug and have never done this, nor heard of this. There might be a real reason why you need to do it, but her explanation is fishy.
posted by zug at 12:48 PM on October 20, 2012

As far as I know it isn't law but it is certainly good practice. Drug diversion is a real problem and so she is doing a perfectly rational thing to protect her patients and her own medical license. Pain management docs do this all the time.
posted by teamnap at 1:01 PM on October 20, 2012 [2 favorites]

Ostensibly so that she can make sure that you're actually consuming your medication as required and not selling them off. Find another professional that won't automatically treat you with suspicion simply because your medical condition happens to be treated with abusable drugs.
posted by WhitenoisE at 1:04 PM on October 20, 2012 [6 favorites]

Not the law in NY or PA...
posted by the young rope-rider at 1:21 PM on October 20, 2012

This is not unheard of for long-term opiate prescriptions. Google "controlled substance contract." Basically, some docs will ask their pain management patients to consent ahead of time to drug tests or routine pill counts, to make sure they're taking their meds at the prescribed rate rather than (a) blowing through them in a big bender or (b) keeping them to sell. It seems to be especially common at big sorta institutional medical practices (university health centers, big HMOs, that sort of thing) or at dedicated pain clinics where they write a lot of oxycontin/fentanyl/whatever prescriptions and have to go way out of their way to keep their noses clean.

I'm totally not familiar with the legal situation in Rhode Island, and it may be different there. Where I am, this sort of thing isn't a legal requirement, but it is a common cover-your-ass move. A doctor can lose their board certification (or even conceivably get charged with a crime) if they're suspected of running a "pill mill." Taking this sort of precaution makes it easier to argue that you're not a pill mill but a legit pain clinic.

Also, I've never heard of this sort of thing for non-opiates. So basically I'm not sure how relevant it is to your situation, but I figured I'd mention it.
posted by nebulawindphone at 1:28 PM on October 20, 2012

This is good practice. The two primary care doctors I shadowed both required urine screens for all patients being prescribed medication that could be abused or sold. It's routine at that hospital, at least.

I wouldn't take it personally.
posted by Eggbix at 1:29 PM on October 20, 2012 [2 favorites]

While I understand the reasons that some medical providers might request this, I believe that (unless RI has some very unusual law/regulation that I have been unable to find in a cursory google search) you should be able to find another provider who would not require it. At the very least, if you would prefer not to submit to the testing, it's worth calling around and asking about policies.
posted by decathecting at 1:35 PM on October 20, 2012 [1 favorite]

It's good practice for the doctors to cover their ass, but in my opinion it's degrading for a patient to have to regularly piss in a cup to prove that they're not a drug dealer. You are paying for this healthcare, and there is no benefit to the patient that I can see.

There is no reason for you to do this if it makes you at all uncomfortable. This is like giving a cop permission to search your car without probable cause. Some people will do it just to prove they have nothing to hide, and some people consider it a gross and indecent invasion of privacy.
posted by WhitenoisE at 1:39 PM on October 20, 2012 [11 favorites]

As far as switching docs goes: On the one hand, my experience is that different docs vary a great deal in terms of how strict or lax they are with this stuff, so switching might well let you avoid the test.

On the other hand, doctor-shopping is itself something that's gonna look pretty suspicious, especially if you're looking for schedule II meds, and especially if you're explicitly shopping around for a place that doesn't do urine tests.
posted by nebulawindphone at 1:39 PM on October 20, 2012 [3 favorites]

^I think doctor-shopping is trying to get multiple medically unnecessary prescriptions for recreational drugs by going to several doctors and hiding your recent medical history. Trying to find a doctor you feel comfortable with isn't doctor shopping.
posted by WhitenoisE at 1:42 PM on October 20, 2012 [3 favorites]

To be honest, if this is not required "by law" as opposed to office policy, I would be more concerned that this professional lied to you. I would seek another provider for that reason alone.
posted by HuronBob at 1:46 PM on October 20, 2012 [17 favorites]

This is done to make sure YOU ARE TAKING it as opposed to selling it. I am not sure about the law, but my doctor tested me when I had a Vicodin prescription for an injury. Once they prescribe more than a certain number of times, they want to make sure you are not selling or giving them away and are actually taking it.
posted by JohnnyGunn at 1:52 PM on October 20, 2012 [3 favorites]

My daughter has to have her urine tested periodically because of her ADD meds. Not sure if it is state law or just the policy of her shrink. She is in Minnesota.
posted by Serene Empress Dork at 2:13 PM on October 20, 2012

Looking at what others have said, I would absolutely refuse to pay, out of my own pocket, an "I don't trust you" fee to piss in a cup.
posted by zug at 2:16 PM on October 20, 2012 [1 favorite]

If you happen to be getting care through a university health system, perhaps by "part of the regulations for prescribing Schedule II drugs," the nurse meant university regulations rather than state or federal ones? I wouldn't be surprised if some universities set stricter standards about this to try to curb potential abuses that others have mentioned.

The Kentucky legislature apparently passed a bill this summer that requires some urine testing when people have prescriptions for controlled substances, including Schedule II. Maybe Rhode Island recently passed or proposed something similar?
posted by stillwater at 2:22 PM on October 20, 2012

This is quite common, and becoming more common with any medication that has street value. I dont prescribe ADD meds, but I sign pain contracts with all my patients on chronic opiates so that everyone is on the same page about the medication. It's for their protection as much as mine, since a signed pain contract lets the other docs in my practice know that its ok to refill meds if I'm on vacation or otherwise unable to do it myself. I do urine tests several times a year with everyone as part of the contract. I do them with everyone so that I'm not in the position of having to decide who seems trustworthy. Even though I go over this as part of the discussion when someone is on chronic opiates, at least several times a year I get a urine test back that shows, e.g., no trace of the medication the patient is allegedly taking on a daily basis in order to function, but is positive for cocaine. The tension between wanting to help your patient and the street value of the pills is an ongoing issue for many, many doctors, judging from how many conference sessions I see devoted to the subject. Just because you have every intention of using them as prescribed doesn't mean that everyone who seeks out ADD meds does.

Rhode Island requires informed consent and a medication agreement for Schedule 2 drugs. The urine test may be a requirement of the practice or institution your nurse works at. It is probably feasible to find someone who doesn't require testing, but it's actually a sign of a practitioner who takes what they are doing seriously.
posted by The Elusive Architeuthis at 2:46 PM on October 20, 2012 [9 favorites]

Not the law in MN, I don't take class IIs but work with people who do. I understand why DRs want to do this, but I personally think doing it without having a suspicion of abuse and/or selling the medication is bad medical practice. How do you trust someone who does not trust you?
posted by edgeways at 4:18 PM on October 20, 2012

I might consider - maybe - consenting to a pill count. Especially if it were actually a freaking opiate, and not Adderall, which is nowhere near Oxycodone or pretty much any of the pain meds on Schedule II in terms of hazardous misuse/addiction risk.

For heaven's sake, this is a psychiatric med, and you have not been identified as a suspected abuser except by merely existing and needing the medication.

Given those facts, If they don't trust your report of what is happening in your daily life to be authentic they have much bigger, more fundamental problems than the potential of you siphoning your meds off to other people. If they don't have the time to actually talk with you and do careful assessments of your condition, and they can't trust you, they have no business prescribing you meds. (Unless you are leaving out the part of the story where you have a history of abusing meds or something, in which case, well, you made your bed, so.)

We are already required to get no more than 30 days of refills at a time. We're already required to wait until the very last minute before picking up the next refill, even if that means going days without your meds because of shortages (thank you so very much, Kroger pharmacy.) We are already required to always physically carry the brand-new written prescription (getting one every single month - no actual refills permitted) to the pharmacy (no phone refills allowed) and we're already limited to a handful of days in an emergency (and many pharmacies flat-out won't do emergency fills of Schedule II stuff, because there's absolutely no difference at all among cocaine, phenobarbital, and Vyvanse.)

Under absolutely no circumstances would I deal with all of that and then additionally consent to urinalysis, absent clear and proper (written, handed to me on a piece of paper I get to keep) legal requirements. I would rather go without my ADHD meds than be mistreated and frankly infantilized in this manner.

You have every right to draw a similar boundary with your physician (and quite frankly, with your elected officials.) You can also play along with their game define your boundaries differently.

Whether it's worth the hassle to you is, of course, totally up to you.
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 4:41 PM on October 20, 2012 [16 favorites]

I don't want this to come off as defensive, but I see a lot of people here saying that they would be okay with a urine test if there was a suspicion of them misusing the medication. However, most of the patients I've identified as diverting have been people with great stories who have seemed totally reliable and who never rocked the boat. Why would they? They were getting exactly what they wanted. From my perspective, testing everyone eliminates the subjective component of deciding who is trustworthy. I have a lot of poor and minority patients, and it's really important to me to be able to say that I treat all my patients in exactly the same way about this--the minority former IV drug user and the white middle class plumber--, because I agree, it's invasive and the restrictions around refills are a giant pain in the ass, and I really do not want to have a conversation accusing someone of misusing medication unless I have evidence in hand. In fact, i hate having these converstions at all--far from a satisfying "gotcha!" moment, they are usually deeply unpleasant and require a lot of time and documentation.

So why do I do it at all? I feel pretty strongly that it's my responsibility to ensure as best I can that the medication I prescribe is taken in a safe way and for the condition it's intended to treat. This includes opiates, but also medication that's not controlled, like blood thinners and insulin. I've had a couple of patients over the years to whom I will no longer prescribe the blood thinner warfarin because they never came in for blood tests to monitor levels and when they bothered they were either too low (which doesn't help them) or too high (which is dangerous). (Fortunately there were reasonable alternatives for their conditions that don't require monitoring).

I'm not saying here that all people on controlled substances can't be trusted or that it's not a reasonable thing to try to find a doctor whose practice style you're comfortable with. But I am trying to make clear that the reason your provider might want to have a contract that involves testing is probably not because she's promoting the nanny state but rather trying to provide good care.
posted by The Elusive Architeuthis at 5:54 PM on October 20, 2012 [1 favorite]

I have never, as an adult, been required to do a urine drop for any scheduled medication, nor would I give my business to a doctor that required such a thing.
posted by elizardbits at 6:29 PM on October 20, 2012 [3 favorites]

This is done to make sure YOU ARE TAKING it as opposed to selling it.

Drug screens are qualitative not quantitative and for some of them very small amounts equal a positive response (such that a Vicks inhaler which contains a tiny amount of L-methamphetamine will render a false positive). Since you could predict when you would be taking the urine test and since amphetamine is only detectable for a few days in urine, you could, if you so chose, take a partial dose every day the week before you would be submitting a urine specimen. (Not that I'm advising you to illegally sell your prescription medication, but after 20ish years of doing analytical work for a drug company HULK SMASH PUNY ENDPOINT ANALYSIS!*)

That being said, my neurologist had me take a periodic blood test (every six months or so) when I was taking Concerta due to the potential for liver toxicity. I use my liver most every day, so this did not seem unreasonable. You're situation is not parallel to mine.

In short, you, or your insurance company, are going to wind up paying for a laboratory procedure that does nothing to further your well-being and is of dubious merit in preventing drug abuse. If this turns out to be a Rhode Island law, it is a pointless boondoggle and my bet would be that it was lobbied for by clinical testing labs.

*I realize most people won't know what endpoint analysis is, but it's hard to sound like the Hulk while talking about the ratio of the analyte response versus the standard deviation of null samples.
posted by Kid Charlemagne at 10:54 PM on October 20, 2012 [4 favorites]

I have been prescribed Adderall in NM and CA just recently, and I've been taking it for a few years now. I've never been asked for a urine test and would not be happy to submit to one if it were legally necessary. If it's not legally necessary, go to another provider who doesn't do urine tests on all patients who take Adderall (or any Schedule II drug).
posted by krinklyfig at 4:58 AM on October 21, 2012

This is done to make sure YOU ARE TAKING it as opposed to selling it.

I am prescribed Adderall as a tool to help me in life, but by no means am I required to take it just because I have a prescription. My psychiatrist and I have talked about this extensively, and I am to consider Adderall useful to me when it is useful, but taking days (and weeks) off is necessary sometimes, but I don't have to figure out ahead of time when those days or weeks might be. I would not wish to be taking it otherwise.
posted by krinklyfig at 5:04 AM on October 21, 2012 [4 favorites]

You are being made to solve a problem that aren't even remotely yours in order to solve your own problem. Why pay for it?

I think it's time to use your Get Out of Jail Free card.
posted by oceanjesse at 6:35 AM on October 21, 2012 [2 favorites]

It may also be done because simply by virtue of having the diagnosis of ADHD, you are at higher risk for *other* addictions— so they may want to be sure you are not taking cocaine or something else on top; it's possible that something you said about your history triggered this concern.

That said, there's actually no data suggesting that the degrading, trust-reducing policy of urine-testing actually *does* deter drug misuse — but it does help cover the doctor's butt so that he or she won't be accused of reckless prescribing. I agree with the doc who posted above that if you are stuck doing it— and in this climate of hysteria around prescription drugs, doctors who prescribe are smart to do so— it should be done for all patients. Typically, of course, what the docs actually do is test the poor, minority patients and not the rich, white ones— who are likely to simply go to another doctor because they find it insulting.
posted by Maias at 2:45 PM on October 21, 2012

My GP told me she'd happily accept the transfer of ADD med prescribing duties from my psychiatrist.

When in the office, she grilled me on why my psychiatrist was labeled in their system as a "child and family psychiatrist," when I am a single adult. Then she lectured me on the dangers of psychoactive drugs and said her personal goal would be to get me off of any meds. Then she said she just needed a urine sample to check my health. She gave me a handout on eating more vegetables and fewer bagels. I am thin/athletic, 5'9", 160lbs, and in terrific shape.

4 hours later the office called and said "hey you are clean!" My response was "clean of what?" "Illegal drugs," they answered.

I called the office several times to complain that I never consented to a drug screen. The office said it was "the law" that they had to do it, and that the doctor would call me back. She never did.

It cost 3x as much for an office visit + drug test than it does to see my psychiatrist.

I went back to my psychiatrist and he said he had never heard of mandatory drug testing for prescribing ADD meds.

As evidenced by the answer from a Dr here, it is entirely a CYA move to drug test. It may be mandatory in the large or university hospital.

You should not be required to submit to and pay for an invasive and irrelevant test to receive medication that may be helpful to you. This is not like monitoring your liver enzymes. This is to brand you as an addict.

Go somewhere else. Be up front that you find it invasive and unnecessary to be tested for drugs. You are an adult (I presume, since you haven't mentioned your parents) and what you do with your body in your own time is your own business.

I am in OR.
posted by MonsieurBon at 6:28 PM on October 21, 2012 [2 favorites]

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