Utility of Urine Drug Tests in Opioid Replacement Therapy

Benjamin Joffe, BA

Sidney Kimmel Medical College

SUMMARY POINTS

• Urine drug tests (UDTs) are recommended for patients in opioid replacement therapy programs.

• There is some evidence that UDTs may decrease mortality, improve abstinence from non-prescription drugs, and increase retention in opioid replacement therapy programs, although the literature is limited.

• There are no standardized guidelines for administering  UDTs, and evidence addressing standardization is lacking.

• UDTs may foster distrust, damage the patient-doctor relationship, and serve as a barrier to patient retention, however further research is required to make definitive conclusions. 

ANALYSIS

Background

Urine drug tests (UDTs) are commonly used for patients receiving treatment for opioid use disorder (OUD). Two opioid replacement therapy (ORT) medications for OUD include buprenorphine, a μ-opioid receptor partial agonist and κ-opioid receptor antagonist, as well as methadone, a full agonist at the μ receptor (1). UDTs detect the presence of drugs and their metabolites, such as amphetamines, benzodiazepines, cocaine, marijuana, and a variety of opioids (2). Two types of UDTs exist. Point-of-care presumptive tests are immunochemical and qualitative, whereas laboratory-based confirmatory tests are performed via liquid chromatography–mass spectrometry, are quantitative, and have lower false-negative and false-positive rates (3).

Of all the matrices that might be used for drug testing, such as blood, oral fluid, hair, sweat, and breath; urine is the most common and best supported (4). However, it is the matrix most susceptible to falsification. One method of tampering involves direct addition of buprenorphine to the urine specimen. Since buprenorphine is metabolized in vivo to norbuprenorphine, UDTs can detect this tampering if the norbuprenorphine to buprenorphine ratio is less than 0.02 (3).

UDTs are potentially beneficial in ORT programs in a number of ways. It has been proposed that UDTs can monitor patients' responses to treatment and their adherence to medications (2-5). Additionally, they help validate self-reported drug use, identify possible diversion, give confidence to providers in their treatment recommendations, and stratify a patient’s risk for overdose (3,5). Patients may be unaware of the drugs present in the substances they use, and UDTs can detect those that pose significant risk of harm (4). UDTs suggesting non-prescription drug use or non-adherence to ORT may lead to increased education, referrals to higher levels of care, and changes in treatment such as dose adjustments or direct observation of medication administration (2).

Analysis

Despite the proposed benefits of UDTs and guidelines recommending their use in ORT, research supporting improved patient outcomes is limited albeit promising. Patients receiving UDT while on Methadone were shown to have decreased all cause mortality when compared to patients not receiving UDTs (6). Contingency management approaches that award patients with take-home doses of medications for OUD in response to negative UDTs are associated with increased abstinence from non-prescription drugs (7). Additionally, there is preliminary data from France showing an association between use of UDTs and increased retention in ORT programs (8). However, this finding is based on only 39 subjects, and two studies are currently ongoing to further elucidate the effects of UDTs on retention (5,9). Non-prescription drug use is reduced for chronic pain patients monitored with UDTs, but studies supporting this finding may be subject to attrition bias, as chronic pain practices often dismiss patients with continued drug use (10-12). A 2014 systematic review that examined multiple clinical outcomes, such as substance use and hospitalizations, determined that there is inconclusive evidence supporting clinical benefits of UDTs in addiction settings (13). More recent literature has agreed with this conclusion (4,5,14). 

When examining UDT impact on treatment, one study found that treatment recommendations were altered due to UDTs in only 0.5% of patients in outpatient addiction evaluations (15). In the setting of chronic pain, for which drug testing has been more thoroughly researched, UDTs have also been found to have a limited impact on patient care, even though providers find them helpful (16). There is little research concerning how providers should address patients whose UDT results are inconsistent with their reported drug use or whose urine specimens have been tampered (4). Providers are encouraged to use motivational interviewing and take an empathetic, nonpunitive, and nonjudgmental approach to preserve their relationships with their patients, but more qualitative or quantitative studies showing effective practices are needed (2-4).

Patients in ORT programs are federally mandated to receive eight drug tests per year at minimum (4). The American Academy of Addiction Medicine recommends for patients on buprenorphine to be tested at least monthly, with higher frequency during initial stabilization on ORT or with recurrent positive UDTs. Many guidelines recommend providers’ judgment in determining precisely how often to use UDTs, in addition to the clinical setting (5,14). UDTs are recommended to be administered at a random schedule, and there is evidence supporting that random interval testing is more likely to detect non-prescription drug use (4,5). There is also evidence that increased frequency of UDTs improves opioid adherence for chronic pain patients (17), though similar research does not exist in the setting of ORT. In fact, a 2001 study focusing on contingency management found no long-term differences in abstinence from substance use between monthly and weekly UDT schedules (7). Despite evidence showing that more frequent UDTs improves clinical outcomes in the setting of chronic pain, more research concerning UDT scheduling in ORT programs is needed (4).

Discussion

Although UDTs are recommended by the Substance Abuse and Mental Health Services Administration and the American Academy of Addiction Medicine (2,4), there is little evidence demonstrating UDTs’ clinical benefits to patients. By helping providers monitor their patients, UDTs may improve mortality and retention. However, UDTs are not without drawbacks. Drug tests can be viewed as paternalistic, promote distrust, and damage the relationship between patient and provider, which is essential in those involving drug use (5). Qualitative evidence supports that patients may be dissatisfied when positive UDTs lead to more frequent follow-up visits (18), and that UDTs potentially serve as barriers to retention in OUD treatment programs (19). In light of these drawbacks, more evidence supporting their clinical benefits to patients is warranted to justify their widespread use and to determine how frequently they should be administered.

REFERENCES

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