Why Drug Test?

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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.

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6 responses to this post.

  1. Posted by Nancy on August 31, 2013 at 10:00 am

    Just wondering what type of testing you do and the cost. I know some patients complain because of the excessive cost when there are cheaper alternative tests available.

    Reply

  2. Posted by xian auren on August 31, 2013 at 10:41 am

    I agree, it helps regulate treatment, and prevent overdoses, it also helps you see where attention is needed. Happy Holiday

    Reply

  3. Concur with your reasoning and clinical practice dynamics. I follow very similar guidelines and base my patient care on evidence based outcomes.
    A patient never questions having their blood pressure, blood glucose, height checked ( weight sometimes is by my patients that are over/ under eaters).
    There is still stigma, sadly.

    Onward- Rich Soper

    Reply

  4. Urine analysis and drug testing is certainly an important therapeutic tool… When that is what it is truly used for. I applaud your making it clear that relapse, or the present of illicit substances, does not a “bad patient” make. It is simply a characteristic and manifestation of the disease your patients are battling. When methadone or buprenorphine patients return a urine analysis indicating the presence of illicit opioids it may very well mean their medication dosage needs to be evaluated if they are “feeling” the illicit opioids. If they are not “feeling” the illicit opioids then further psychosocial reasons need to be explored: Why are they using? Why “waste their money?” When drug testing is used in these ways it is certainly a VALUABLE therapeutic tool.

    Many patients are skeptical at times, I’m afraid, because all too often drug testing is NOT used as a therapeutic tool. Too often opioid treatment programs and DATA 2000 buprenorphine-assisted practices use drug testing as a mechanism of control with overly-punitive “consequences” for illicit returns. The current federal regulations governing OTPs make is clear that drug testing should be a therapeutic tool, but all too often that is not the practice in reality. These negative experiences & stories from other patients in treatment can not be discounted. It’s important to consider the “fear” these all-to-prevalent negative and unethical practices have instilled in many patients… And that might be the motivating factor(s) when patients seem hesitant about drug screens. And if that is the case, as you’ve explained, it is my hope that your explanation of drug testing as a therapeutic tool & not a measure or means of punitive repercussion or negative control will put the hesitant patient at ease.

    Thank you for providing ethical, evidence-based treatment not just in theory but in practice!

    Because treatment works,
    Zac Talbott
    NAMA-R TN
    http://www.methadone.org

    Reply

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