Urine drug screen

I think you have a couple options.

I have an opioid  contract which states I may stop opioids if there are illegal drugs in the UDS, so stopping could be an option.  It could lead to her buying her opioids on the street though.

Stopping suddenly could be very destabilizing given her mental health illness and ? abdominal pain.  If you think it is  better to continue the opioids then perhaps limit the pickups to weekly, so there are no large amts of drug to " share" . Maybe you could discuss the cocaine  use  and  tell her cocaine is no help to her medical/ mental health problems  that with further cocaine use you will taper her opioid, though continue to follow her medical problems with other appropriate medications.

I usually say that I am not comfortable prescribing a controlled substance to anyone using illicit  drugs. So she gets a warning then at the  next occurance ( if there is one) you can take action.

Is the pain fibro pain and is  she on something  more specific for her fibromyalgia? 

Many often tell our patients that if they use cocaine, we cannot prescribe opioids.  This is very reasonable and it is entirely up to the patient to stop.  If you prescribe to a patient that has cocaine in the urine, you can probably assume that they are selling the opioid that you prescribe to buy the cocaine.  Very high risk for diversion.

After a period of stability and clean urines (few months) you can consider prescribing again.

We always need to keep in mind why we are prescribing opioids, and need to demonstrate a positive outcome with the prescribing - otherwise why are you prescribing the opioid?

If you look at the prescribing guidelines, a patient with a history of substance use disorder, especially a current substance use disorder, it is recommended not to prescribe opioids - so if you do there needs to be comprehensive documentation in chart explaining the deviation from the guidelines.

Has she admitted to using cocaine? Is it a false positive reading? Is the analysis completed by a lab using Gas Chromatography Mass Spectrometry or GC-MS) test. When initial screening drugs tests (called immunoassays) result in positive results, a second confirmatory (Gas Chromatography Mass Spectrometry or GC-MS) test - which should always be done on positive results - greatly lessens the chance of a false positive, almost reducing the risk to zero.3 GC-MS is a very specific test to identify separate compounds within a sample. However, GS-MS can also lead to a false negative if the GC-MS column is not designed to identify all potential compounds.1

I would push pause and ask her to come in for a conversation. 

It's true that the sample could be a false positive (though cocaine isn't typically a cause of false positives). She could have used or been in contact. The question is what's going on. Was it a one time thing? Is it part of more frequent and therefore problematic use? Is she experiencing a destabilisation of her BPAD that led to cocaine use, or that could have been triggered by cocaine? Assuming that she's selling her codeine for cocaine is a big leap. More likely she's using both.  

I think codeine probably isn't going to be a great option for her fibromyalgia and IBD long term anyway, but I wouldn't stop immediately based on one sample. Give her a chance to explain, and try to use the relationship to see what's really going on and help her in the big picture.