Frequent drug tests in addiction treatment have become a common practice despite proven benefits of such testing. When do tests become the end instead of the means to health and wellness?
In a previous post, I have explained how there was no agreement on the frequency of drug testing in Canada. Not until March 2018, when the British Columbia Centre on Substance use released the National guidelines for opioid use disorder. This article looks at the scientific evidence (or the lack of it) for frequent drug testing in addiction treatment. Read more or watch podcast below:
What is the study about?
We wanted to find out whether frequent urine drug tests correspond with better outcomes of treatment with opioid agonists such as methadone or buprenorphine.
How we did the study ?
We looked at the scientific literature from 1995 up until the end of 2017.
Then, we wanted to see how often the screening should be done while in the opiod agonist treatment. In the study, we included people of any gender, age or ethnicity.
Frequent drug tests lack evidence
We found only one higher quality studies with patients from USA
The study compared weekly and monthly urine drug testing with take-home doses of opioid agonists
Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern
Why is the study important?
Opioid use disorder is a chronic condition impacting the reward, motivation and memory pathways of the brain (ASAM, 2017).
Opioid agonist therapy is a first-line treatment for opioid use disorder.
The frequency and role of urine drug screening in opioid agonist treatment has received little research attention.
Although prior evidence suggests that testing frequency reflects philosophy and practice context, rather than differences in patient characteristics or clinical need, frequent urine testing remains under-researched.
Finally, the editorial of the Canadian Journal of Addiction featured this study as important for bringing additional management aspects for consideration:
McEachern J, Adye-White L, Priest KC, Moss E, Gorfinkel L, Wood E, Cullen W, Klimas J: Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. International Journal of Drug Policy 2019, 64:30-33.
Clinicians commonly use urine drug tests to detect or validate self-reported drug use, particularly when beginning and maintaining opioid agonist therapy (for example buprenorphine or methadone). Until now, there has been no clinical consensus on urine drug testing frequency in Canada.
National guidelines for opioid use disorder released: Canadian consensus on urine drug testing frequency
Vancouver, B.C. [March 5, 2018] — “A first of its kind Canadian guideline setting out best practices for treating people with opioid addiction has been released today. The national guideline was based on provincial guidelines developed by the BC Centre on Substance Use (BCCSU) and implemented in British Columbia last year.” This guideline has been federalized and published in the Canadian Medical Association Journal. Health care professionals should follow the new guidelines.
Large Variation in Provincial Guidelines for Urine Drug Tests during Opioid Agonist Treatment
Before the new guidelines, each province had their own guidelines for treating opioid addiction. At that time, there was no summary of the published clinical practice guidelines for urine drug tests in Canada. Also, no one measured the consistency with which different provinces suggested administering drug screening. In June 2017, the American Society of Addiction Medicine released the national consensus document for appropriate use of drug testing.
Therefore, we looked at all policies and guidelines for Urine drug screening in Canada, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our recent provincial guideline and policy scan found that urine drug screening frequency recommendations vary greatly among Provinces for persons receiving opioid agonist therapy for opioid addiction.
To read the whole story, please visit the journal website www.canadianjournalofaddiction.org or lookup the paper using the following citation:
Moss, E., McEachern, J., Adye-White, L., Priest, K., Gorfinkel, L., Wood, E., Cullen, W., Klimas, J. (2018) Large Variation in Provincial Guidelines for Urine Drug Screening during Opioid Agonist Treatment in Canada. Canadian Journal of Addiction, 9(2):6-9
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Against the use of opioids for chronic non-cancer pain to people who have active substance use disorders advises the third recommendation in the new opioid therapy guidelines (May 8th, 2017).
However, this “strong” recommendation is based on low quality of evidence from studies that rarely involve people with active substance use disorders (SUD).
Here, we first highlight the main caveats in the research of pain treatment among people with SUDs, why this has been the case and then we offer potential solutions for overcoming the obstacles in clinical research and policy.
Most clinical trials of pain medications exclude people with SUDs. Denying treatment of pain with opioids to people with active SUDs in the absence of evidence, based on a presumed potential for “more” addiction and documented adverse side effects (overdose), is cautious. However, it is also likely influenced by stereotypes and stigma towards people who use drugs and it further discriminates people with SUDs. Instead of stigma, the society should seek better ways of increasing rapid access to evidence-based opioid agonist therapy for prescription opioid use disorders (see Ahamad & Socias, 2016).
Moreover, this approach can lead to unanticipated consequences, such as seeking illicit drugs (see Voon et al, 2015). It is clear that we need more research to better understand pain treatment among people with SUDs and to give better recommendations to clinicians. But what kind of further research? Firstly, we need clinical trials that specifically include people with SUDs, such as people receiving opioid agonist treatment (Ti et al., 2015). If trialists refuse to include people with pain and concurrent SUDs into pain trials, presumably because of their high-risk for more SUDs, this obstacle can be overcome by including a standardized measure of pain, like the VAS, into every pharmacotherapy trial of SUD treatment.
Which pain patient treated with opioids will develop opioid use disorder?
Secondly, we still don’t know which pain patient treated with opioids will develop opioid use disorder (OUD). Despite the typical occurrence of OUDs among approximately 5.5% of the study populations in pain trials, there is no evidence for a reliable predictor of who will develop OUD. We need to find valid risk indicators.
Finally, the current opioid overdose crisis in many countries is primarily driven by not-as-prescribed-use of fentanyl – an anesthetic used to tranquilize elephants. What if people with opioid use disorders self-medicated their pain with fentanyl (see Voon et al., 2015)? What if their pain, both emotional and physical, was as big as elephants and we had nothing for them? What we offer to them is suspicion, exclusion, denial and mistrust. We should offer compassion and fairness.
- Busse, J. W., et al. (2017). “Guideline for opioid therapy and chronic noncancer pain.” Canadian Medical Association Journal 189(18): E659-E666.
- Socias, M. E. and K. Ahamad (2016). “An urgent call to increase access to evidence-based opioid agonist therapy for prescription opioid use disorders.” Canadian Medical Association Journal 188(17/18): 1208.
- Ti, L., et al. (2015). “Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs.” Pain Research & Management 20(2): 84-88.
- Voon, P., et al. (2015). “Pain among high-risk patients on methadone maintenance treatment.” The journal of pain 16(9): 887-894.