Every so often one of my established office-based buprenorphine (Suboxone) patients gets a little rebellious about being asked to take drug tests. They feel since they’ve been doing so well for so long, they no longer need urine drug tests. They say things like, “Don’t you trust me by now?” But it’s not about them or their character. It’s about the disease of addiction. I tell them some abbreviated form of the following:
• Patients in treatment don’t always tell me when they’ve relapsed. In order for addiction to thrive, lies must be told. Otherwise honest people sometimes tell outrageous lies while they are in the throes of addiction. I see this as part of the disease. It’s not about them. It’s not about me. It’s the addiction.
• It’s good medical practice. Like many chronic illnesses, relapses happen. It’s better to detect these as early as possible, to discuss what happened, and if/how we need to change their treatment. If a patient has relapsed to opioids, it may mean that I need to increase the dose of buprenorphine, if they were still able to feel an opioid high. If the relapse was to other drugs, it usually means we need to increase the “dose” of addiction counseling.
• There’s a gold mine of information in relapses. I ask my patient what happened immediately before the relapse. Was she around people who were using drugs? Did she use drugs to try to get rid of an unpleasant emotion? Did she use drugs because she became complacent? The answers can help decide how best to avoid relapses in the future. If a patient is fortunate enough to live through a relapse, she can get information she can’t get any other way.
• Drug screening benefits the patient by giving them accountability. Some patients are less likely to relapse with accountability. I’ve had patients say that the thought of having to talk about a relapse is enough to keep them from using drugs. This surprised me, but I’m glad.
• Drug screening also shows them I’m serious about their recovery. I’m not just going through the motions of writing a prescription and getting paid for the visit. I really want my patients to recover and get their lives back.
• I’m not a human lie detector. In the past, I smugly thought I could tell if someone had relapsed, so drug screens just confirmed what I already knew. After more experience, I know that’s not true.
• It’s the standard of care. Even if the other reasons aren’t compelling enough to do drug screens, the vaguely increased regulatory oversight of doctors who prescribe buprenorphine should induce them do drug screens. I know if my charts are ever audited by the DEA, my state’s department of health and human services, or my state’s medical board, I can show I’m doing things in the proper manner.
• I don’t want to prescribe medications that will be diverted to the black market. Some doctors say, with some justification, that buprenorphine is a safer drug than most other illicit opioids, and we should look at black market diversion of buprenorphine as a form of harm reduction. However, governmental types don’t see things that way. The DEA certainly doesn’t. I don’t want to prescribe buprenorphine to people with the criminal intent of selling part or all of it. When I do urine drug screening, if there’s no buprenorphine present, that’s a serious matter. If the patient isn’t using what I prescribe, it’s likely they are selling it. Since such diversion of buprenorphine endangers the whole program, it’s essential to stop prescribing for people who sell their medication.
These are my reasons for drug screening. Since I’m not going to stop doing them, addicts who refuse drug testing have to find new doctors. New opioid addicts who come to my office are told, both verbally and in writing, that I do drug screening. They can make their own decision about whether they want to see me as their doctor or go elsewhere. Most established patients comply with requests for testing after I explain the above reasons.