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Toxicology Testing for Improved Adherence and Outcomes in Pain Management

Chronic pain is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression, Alzheimer disease and related dementias, higher suicide risk, and substance use and misuse.

A 2023 study from the National Institutes of Health shows that new cases of chronic pain occur more often among U.S. adults than new cases of several other common conditions, including diabetes, depression and high blood pressure. Among people who have chronic pain, almost two-thirds still suffer from it a year later.

Overall, the study found that the rate of chronic pain and high-impact chronic pain (HICP) among adults is approximately 21% and 8%, respectively. Chronic pain is pain that is experienced on most days or every day in the past three months; and HICP is pain that limits life or work activities on most days or every day during the past three months.

Opioids can be essential medications for the management of pain; however, they carry considerable potential risk. Long-term prescription opioid use was found to be associated with increased risk for overdose and opioid misuse, among other risks.

In 2022, the CDC updated its clinical practice guidelines, which include recommendations for clinicians providing pain care, including those prescribing opioids, to ensure clinicians and patients considered safer and more effective pain treatment, to improve patient outcomes, and to reduce the number of persons who developed opioid use disorder, experienced overdose or experienced other prescription opioid–related adverse events

Included in the guidelines, the CDC recommends that clinicians consider toxicology testing to assess for other prescription and nonprescription controlled substances, including nonprescribed and illicit opioids and benzodiazepines, that may increase a risk of overdose when combined with opioids.

At Navis Clinical Laboratories, an analysis of drug test samples from patients being treated for chronic pain revealed unexpected and potentially dangerous results:

  • 13% of drug tests were positive for illicit drugs a review of prescription data could not identify
  • 21% of drug tests were negative for prescribed oxycodone or morphine
  • 41% of drug tests positive for an opioid and benzodiazepine were unexpectedly positive for one or both drug classes

Analysis of 93,422 chronic pain patient drug test samples; Jan – Dec 2018

Toxicology testing should not be used in a punitive manner but should be used in the context of other clinical information to inform and improve patient care. In addition to identifying information about drug use that is not reported by the patient, toxicology tests can assist clinicians in identifying when patients are not taking opioids prescribed for them. While in some cases this may indicate diversion, it may also reveal clinically important issues. Discussion with patients before and after testing can sometimes yield a candid explanation for the unexpected results. For example, a patient might explain that the test is negative for prescribed opioids because they felt opioids were no longer helping or they were experiencing difficulties with adverse effects and discontinued them.

Utilization of Navis’s toxicology testing and protocol management reporting tools revealed improved patient adherence to treatment plans and risk mitigation:

  • 26% increase in samples testing positive for prescribed medications
  • 36% decrease in samples testing positive for unexpected drugs
  • 19% decrease in samples testing positive for illicit drugs
  • 20% decrease in samples testing negative for prescribed medications


n=440 and n=283 samples tested for health system’s primary care center in Q1 2017 and Q4 2018, respectively

Another tool for clinicians who prescribe opioids is Navis’ CORE (Comprehensive Oral Fluid Rx Evaluation) testing. CORE is the first steady-state oral fluid test that identifies whether a medication is present at a level consistent with the prescribed dosing regimen. This non-invasive test can help clinicians determine if patients are taking their medication as prescribed or if there are metabolic or health issues interfering with the treatment protocol.

In 2020, among patients who reported misuse of prescription opioid medications during the past year, 64.6% reported the main reason for their most recent misuse was to “relieve physical pain” (compared with 11.3% to “feel good or get high” and 2.3% “because I am hooked or have to have it”). CORE testing can help facilitate an open and honest conversation about why a patient may be taking more (or less) of their prescribed medication and allow the clinician to adjust the dosage or medication for better relief of pain or alleviation of side effects.

Navis Clinical Laboratories is proud to partner with clinicians to provide innovative, data-driven solutions that support a person-centered care approach and enhance chronic pain treatment protocols and harm reduction strategies. Contact us to learn how our solutions can help elevate your treatment protocols.


Nahin RL, Feinberg T, Kapos FP, Terman GW. Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020. JAMA Netw Open. 2023. doi: 10.1001/jamanetworkopen.2023.13563

Rikard SM, Strahan AE, Schmit KM, Guy GP Jr.. Chronic Pain Among Adults — United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72:379–385. DOI: http://dx.doi.org/10.15585/mmwr.mm7215a1

Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1

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