Drug Testing

drugtest47

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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9 responses to this post.

  1. Posted by Bob Oz on August 10, 2014 at 11:37 pm

    I agree with everything you said. I’ve been taking Suboxone since 2006. I am screened often. I have not relapsed in 8 years, not to say I couldn’t.

    Reply

  2. I so wish that you were the medical director at the treatment center that I attend.The three medical directors that have been at the treatment center where I am a patient have little to no experience and do some of the most off the wall things that I have ever seen and I have been in treatment for a very long time at several clinics.These directors are not ASAM and get very hostile when ask about their experience. I hope you continue to practice Addiction Medicine. The field of Addiction Medicine needs more Physicians with the passion that you have.
    PMLP

    Reply

  3. Posted by Carlos on August 16, 2014 at 8:32 pm

    The problem is that urine test carries l a long history of nightmare for patients too many facilities use the test as a weapon rather than the therapeutic tool and attitudes that too frequently means trouble for the patients. I don’t know how many times I have had false positives. The chemical companies denied to gave the impression that the test was highly valid and reliable and would deny that there would be any errors. I don’t know how much validity has improved ifvany

    Reply

  4. Posted by Bernard Foster on September 17, 2014 at 2:19 am

    Such a great passion for helping addicts recover. I hope you will continue to help more patients to have a successful recovery. In the field of addiction medicine you need to show a genuine concern for your patients for them to feel that they are valued and loved.

    Reply

  5. Posted by Shaun on October 17, 2014 at 5:32 pm

    I don’t think that patients should be kicked out of maintenance programs for testing positive for THC. If a person is seeking help for an opioid addiction, they will suffer more by being kicked out of a recovery program for smoking pot.

    Reply

  6. Posted by Jason r on November 10, 2014 at 11:49 pm

    First thank you for your blog. Great stuff! I’m an addict in recovery, and have been on subutex for around 4 years. I relapsed about 3 months after I started and failed a drug screen. My Dr was pretty good about it, I basically told him that the program was the best thing in my life and I wouldn’t let him or myself down again. He accepted that and we moved on. Well about a month ago I took to much meds, a extra half here a extra half there, and I showed no subs in my urine test. He kinda made a big deal and I lied and started I didn’t know why it didn’t show up.. He wrote my prescription and I left. Well now this month I had a family emergency and work out of town and now I’m will be exactly 11 days late for my appointment. I know this is going to look terrible to him, I even bit the bullet cause I knew I would be late and only took a half a dose every other day to make sure it shows on my drug screen. I’m still very nervous about going in for appointment tomorrow but I’m going and I’m going to tell the honest truth and see what happens. I guess he kill me for it but if he discharges me he might as well .

    Reply

  7. Posted by Marchalla on January 31, 2016 at 1:02 am

    I’ve been on the clinic for two years & 3 months. NEVER had a call back until Friday my take home day. Well I was called on later Friday evening for a call back on Saturday the next day. I went back with ALL 6 of my bottles. I the nurse took Saturday & Sunday out . We went in the restroom she threw the remaining four down the sink . Yes down the sink ???. After she open them up n the seal pop open on a few but hadn’t been tampered with . I drink my Saturday in front of her . She gave me my Sunday. And told me I had to return to the clinic on Monday to see the doctor. So I asked was the doctor gonna give them all back . She replied I’m not sure you’ll have to see what he said . I’m upset three times to this clinic . Where’s my privileges I gain for doing well over 2 yr ?? Uggh

    Reply

    • Hmmm…not sure what that means…depending on the type of system used to seal the bottle, sometimes they don’t seal completely. I suspect the nurse wanted the doctor to make the decision. Be patient, and see what they say. You did well by coming in when asked, with the correct number of bottles, so it should be oK

      Reply

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