With increased urine drug screening to monitor patients taking opioid painkillers, doctors also are ordering tests to reveal use of drugs such as cocaine and methamphetamines.

But testing for illicit drug use — requested by physicians, who can bill for conducting the tests in their offices or for sending urine samples to a lab for analysis — increases workers compensation payer costs and raises questions about the necessity of the tests.

Various medical-treatment guidelines for treating injured workers call for periodic urine drug testing when doctors prescribe addictive opioid pain medications long term. That testing helps doctors learn whether patients are complying with opioid prescribing directions and not engaging in inappropriate behavior such as illegally selling the drugs or doctor shopping for multiple prescription refills.

A recent analysis of medical expenses for treating injured workers in Michigan and Tennessee surprisingly uncovered a substantial increase in bills for tests looking for the presence of drugs such as cocaine and methamphetamines, said Jeffrey Austin White, director of medical management practices and strategy for Accident Fund Holdings Inc. in Lansing, Mich. Those charges are being combined with billing for opioid prescription compliance testing, he said.

Paying for monitoring a prescribed opioid medication's use seems appropriate for a workers comp insurer aiming to keep injured workers safe while helping them return to work, Mr. White said. But he wonders if the insurer should be on the hook for the testing of illegal drugs.

“The providers are prescribing opioids, they are not prescribing methamphetamines, they are not proscribing cocaine,” Mr. White said. “They are prescribing opioids purely to relieve pain and to get the person back and functioning. So why is it all of the sudden the responsibility of a work comp carrier to pay for all these additional tests?”

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For Accident Fund, a workers comp insurer, the practice has pushed costs up to $1,200 from $200 each time a set of tests is conducted, Mr. White said.

What's more, a 2012 California Workers' Compensation Institute study evaluated more than 450,000 opioid drug tests conducted on injured workers in California between 2004 and 2011. The Oakland, Calif.-based institute found a “viral-like growth rate in the volume of drug testing and in the amounts billed and paid for these services.”

Drug testing medical visits climbed to 186,023 in 2011 from 4,012 in 2004, according to the study. Meanwhile, the average amount paid for the tests increased 315%, to $148 in 2011, from $36 in 2004. Consequently, total drug testing payments rose to $27.4 million in 2011, from $142,481 in 2004.

The California institute has begun gathering fresh data to update the study and research the cost increases when testing for illicit drugs is added in, said Alex Swedlow, the institute's president.

Several medical treatment guidelines do call for doctors prescribing opioids to also test for illicit drug use under certain circumstances, such as when addiction or abuse is detected or when patients are at risk for overdose and death, sources said.

Doctors need to identify patients abusing drugs because it is inappropriate to provide them opioids and it can change the treatment required for them, said Michael J. Shor, managing director of Best Doctors Occupational Health Institute in Boston.

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“If you have a patient who is addicted ... they will be using multiple things, and if they are addicted you certainly need to have a different approach to how you deal with them clinically,” Mr. Shor said. “And drug testing is one of the best tools you have to manage that process because, unfortunately, once a patient becomes addicted, getting truth out of them is a high art form.”

Tests revealing that patients are using drugs for other than “clinical health” can also help workers comp payers arguing before a judge or hearing officer regarding their responsibility for the claimant, Mr. Shor said.

Doctors should consider ordering tests for illicit drugs because they can help determine whether prescribing opioids to certain patients will cause additional problems, said Dr. Dwight Robertson, national medical director for Reno, Nev.-based Employers Holdings Inc.

Testing can run amok, however, when doctors view it as a profit generator, he said.

To prevent that, Employers has discussed the billing issue with doctors suspected of ordering more tests than necessary. The workers comp insurer's contracts cap the amount testing labs and doctors can charge for the drug tests, making the tests well worth the expense, Dr. Robertson said.

Ultimately, though, how doctors follow up on the test results is more important than the conducting of the tests, said Kathryn Bronstein, vice president of medical affairs at Ameritox Ltd., a Baltimore-based pain medication monitoring company.

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“You should be testing for a reason, and then when you get the test results back, you modify your treatment plan based on the urine testing results,” she said.

But Accident Fund's Mr. White said that overall he isn't seeing evidence of doctors adjusting treatment plans or requesting new therapies that would indicate tests for illicit drugs are producing adverse findings.

“They are not sending (claimants) to addiction programs,” Mr. White said “We would be funding that, so we would know.”