Clinical Responses to Cocaine-Positive Urine Drug Screens in Patients Receiving Chronic Opioid Therapy: A Four-Patient Case Series.

Background: Urine drug screening (UDS) is commonly incorporated into the monitoring of patients receiving chronic opioid therapy for noncancer pain. Detection of an illicit substance such as cocaine creates a challenging clinical situation because continuation of full µ-opioid agonist therapy may carry increased risk, while abrupt or reflexive discontinuation may also have unintended consequences. There is limited literature describing how clinicians modify chronic opioid therapy following cocaine-positive UDS results. Case Series: We describe four patients receiving chronic opioid therapy who were found to have cocaine-positive UDS results. Two patients receiving hydrocodone/acetaminophen were gradually weaned from opioid therapy and opioids were subsequently discontinued. A third patient receiving hydrocodone/acetaminophen was transitioned to buprenorphine/naloxone 2 mg twice daily as an alternative to continued full agonist opioid therapy. A fourth patient with a history of substance misuse and prior spine surgery was offered transition to buprenorphine/naloxone but declined and elected not to continue care with the practice. Conclusion: Cocaine-positive UDS results may substantially alter chronic opioid prescribing. Management may include increased monitoring, gradual discontinuation of full agonist opioids, or consideration of buprenorphine-based therapy in appropriately selected patients. These cases emphasize the importance of individualized risk assessment rather than a uniform response to an unexpected UDS result.