Increase in Urine Testing Raises Ethical Questions Travis Dove for The New York Times At the Ameritox lab in Greensboro, N.C., samples are used to determine if patients are taking the proper medication. As doctors try to ensure their patients do not abuse prescription drugs, they are relying more and more on sophisticated urine-screening tests to learn which drugs patients are taking and - just as important - which ones they're not. The screenings can tell what drugs people are taking, and also if they are not taking the drugs they have been prescribed. The result has been a boom in profits for diagnostic testing laboratories that offer the tests. In 2013, sales at such companies are expected to reach $2 billion, up from $800 million in 1990, according to the Frost & Sullivan consulting firm. The growing use of urine tests has mirrored the rise in prescriptions for narcotic painkillers, or opioids. But the tests, like earlier efforts to monitor opioid prescribing, have led to a host of vexing questions about what doctors should do with the information they obtain, about the accuracy of urine screens and about whether some companies and doctors are financially exploiting the testing boom. For one, the tests are showing that large numbers of pain patients are not taking prescribed drugs or are taking substances not given them by a doctor. For example, a recently published study of 800 pain patients treated at a Veterans Affairs facility in North Carolina found that one-quarter of them tested negatively in a urine-screen test for a drug they had been prescribed, while 20 percent of patients tested positively for an illicit drug or a narcotic painkiller that was not prescribed. Such findings are in line with data recently released by Ameritox, one of the country's biggest urine-screening laboratories. In reviewing some 500,000 tests it analyzed in 2012, the company said that about one-third of the tests failed to detect the drug prescribed by a doctor. In about 75 percent of those cases, the drug at issue was a narcotic painkiller, Ameritox said. The simple fact that a patient tests negatively for a prescribed drug does not necessarily mean they are selling it; it could simply mean they decided to stop taking it. Still, doctors say they now face tough choices about what to do with patients when tests show they are not taking prescribed drugs or are mixing them with unapproved drugs or illegal ones. For example, Dr. Roger Chou, who helped develop urine-screening guidelines for a professional medical group, the American Pain Society, said he believed that the tests were a valuable tool. But he added that he was concerned that doctors, to protect themselves, would use the tests as an excuse to drop, or "fire," patients rather than steer them into addiction treatment or alternative pain management programs. "I think that it is problematic from an ethical perspective," for doctors to fire patients, said Dr. Chou, a professor at Oregon Health & Science University in Portland. Another specialist, Dr. Daniel Alford, says he typically has a discussion with a patient to describe unexpected test findings and their relevance to pain treatment. For example, if an illicit drug is found, he will tell patients that the use of such a drug also means they are more likely to abuse the narcotic painkiller that he is prescribing them. But such talks may have only limited success, and some patients continue to test positive for illicit drugs, said Dr. Alford, who is a professor at Boston University. He offers to help them get addiction treatment. "Some of those patients drop out of the practice and some of them stick around," he said. Urine tests are by no means the first technique that doctors have used to try to better monitor how patients are using prescription narcotics. A decade ago, so-called pain contracts - agreements that essentially allowed a doctor to refuse to continue treating patients who tried to get opiods from other physicans - were popular. The agreements, however, proved to be of limited value, so pain specialists turned to diagnostic questionnaires that were supposedly able to predict whether a patient was likely to abuse a narcotic because of factors like a family history of substance abuse. The predictive value of such questionnaires, however, is still not clear. One review found that 60 percent of patients who abused opioids scored low, rather than high, on one widely used screening questionnaire. Subsequently, doctors have turned to urine tests. There are two basic types and they vary markedly in accuracy and cost.