Archive for the ‘drug tests’ Category

Cutting Edge Addiction Medicine Information

 

 

 

The last issue of Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM), was full of interesting articles, and I plan to blog about some of them in upcoming entries.

I’m pleased to be a member of ASAM, recognized as the premier professional society dealing with substance use disorders and their treatments. This organization has members with great enthusiasm, and hosts the best conferences I’ve ever attended in my career as a physician. The journal ASAM publishes is also top-notch. They publish articles pertinent to issues addiction medicine physicians face daily. They are practical for my everyday use.

Today I’m blogging about their drug testing recommendations.

Recently there’s been an upsurge of laboratories offering fantastic deals to physicians and patients which in the long run may turn out to be not so fantastic. ASAM published a document giving evidence for the most appropriate way to use drug testing in the setting of addiction medicine practices.

This document underwent extensive evaluation by experts in the field, using a data search for the highest quality of evidence, and then, using the RAND/UCLA appropriateness method, decided the importance of all of the data gleaned. Then an expert panel judged the ratings of all statements concerning drug tests. IRETA (Institute for Research, Education and Training in the Addictions), the prestigious group in Pennsylvania, also contributed to the document.

ASAM mailed a copy of the entire document, titled, “The Appropriate Use of Drug Testing in Clinical Addiction Medicine,” along with the latest issue of the Journal of Addiction Medicine.

I recommend every physician working with patients with substance use disorder read this document and use its information. The document isn’t meant for federally mandated workplace forensic testing, only for addition medicine practice.

In this blog, I’m going to point out a few of the ideas in the document and comment on them.

The ASAM document points out that drug testing technology is useful only when the technology is used appropriately. This reminds providers that we must understand the underlying principles of drug testing, know the limits of this technology, and remember it’s only one tool in our toolbox of patient evaluation.

They remind us that there’s only limited evidence to show that drug testing improves patient outcomes. More recent studies suggested that when drug testing is used correctly and integrated into making treatment decisions, outcomes may be improved.

Physicians shouldn’t use drug tests in a punitive, confrontational way. Rather, if we get an unexpected result on a drug test, it should be the beginning of a conversation with our patient about the result, not the end of treatment for the patient.

Some patient advocates point out that if patients have no adverse consequences for positive drug screens, self-report of drug use would be sufficient. That’s probably true, but if a patient continues to use drugs while in treatment, a change in treatment may be needed. Patients view intensification of counseling as an adverse consequence, so there we have a dilemma. As a physician, I may feel that positive urine drug screens indicate a need for more intensive treatment, but my patient doesn’t want that, and feels that I’m being punitive for insisting on more intense treatment.

That’s not unique to addiction medicine. In primary care, I often recommended patients participate in more intense treatment for a chronic disease. Sometimes they felt like I was making a fuss about nothing.

For example, I had a patient with extremely high blood pressure. He ran 220/130 on a regular basis, and refused hospitalization saying, “That’s normal for me. That’s just what my blood pressure runs.” OK, maybe that’s true, but it’s still dangerously high. When my patient refused to take a second medication for blood pressure, refused to get necessary lab tests done, and missed follow up appointments, I had to decide whether to continue to see him as a patient or dismiss him for non-compliance. He was a time bomb, at high risk for a stroke or heart attack. If I kept seeing him, maybe I could gradually convince him to take more blood pressure medicine. By continuing to prescribe blood pressure medication, I was doing something to reduce the possible harm to him. But if he had a large stroke and died under my care, am I partly liable because I kept seeing him despite his non-compliance?

I eventually decided I couldn’t keep seeing him since I was more worried about his health than he was. He did view my dismissal of him as a patient as punitive. I guess it was, in a way, yet I hoped he’d find a doctor better able to convince him to take care of his disease.

Drug testing should be therapeutic. This means that that the drug test should be used as a tool, but not a club. A positive test can serve as a starting point for a discussion about denial, motivation, and about the actual substances used. A positive test can become a starting point that leads to helping patients understand some of their triggers for use.

For example, when I talk to a patient about an unexpected drug test, I say something along the line of, “Tell me about the cocaine (or whatever drug).” I want my patient to talk through how the drug use occurred, especially about what was going on just before they decided to use the drug. Who were they with, what were they doing, what was their mood and attitude like, how was their stress level…all of these things can lead to helpful information. Often, before the actual drug use, there’s a sequence of events leading up to the use. I tell patients that relapses often contain valuable information they can use in the future, and since they didn’t die from the relapse, they should mine the experience for all data that can be helpful in the future.

This should be a collaborative process, assuming the patient sees the drug use as change-worthy behavior. If the patient sees no problem with using a drug, a completely different approach is needed, because you’re trying to sell a dog to someone who prefers cats.

ASAM’s document us that the intent of the test is to discover whether a substance has been used within a particular window of time.

That would seem obvious, but sometimes providers expect the test to tell them more than that, or less than that. For example, if a patient sample tells us whether a substance has been used over the past 4-5 days, it will not tell us if the patient is impaired or under the influence of that substance at one particular time over the past 4-5 days.

A test can’t give us information outside of the test’s expected window of detection. That should be obvious, but it bears repeating, because some providers can get confused.

For example, a non-medical acquaintance who claimed to be an expert in toxicology recently told me his organization planned to use hair testing for buprenorphine patients. That made no sense to me. The window of detection for hair is great for weeks to months, depending on the length of the hair sample, but it won’t tell me if my patient has used drugs over the past few days or week. That data won’t be part of the hair follicle record until more than a week from now. I would regard that as stale data, not as helpful to me clinically.

The ASAM document agrees, saying that hair drug testing is not appropriate for most addiction medicine treatment settings. Also, I would add that it’s costly, not timely, and possibly discriminatory, since dark hair concentrates drugs more than pale hair.

The ASAM document made a few points I had not considered. One would expect that any patient in treatment for substance use disorder would know what her urine drug screen would show. That’s not always the case. For example, with heroin, the person using the drug may have no idea that it’s been mixed with fentanyl, a much more powerful opioid that heroin. That’s a common practice now, since drug cartels have discovered it’s cheaper to make fentanyl than harvest opium and process it into heroin.

That’s some valuable information for a patient who thinks he’s using heroin. If fentanyl, a much more powerful opioid than heroin, is contained in the product he’s using, he may be more likely to do “tester” shots to avoid overdose.

I’ve had patients who use marijuana suddenly test positive for both THC and methamphetamine. Was the marijuana mixed with methamphetamine? If the patient knows for sure she hadn’t intentionally used methamphetamine, it must have been mixed with the marijuana, possibly to give the user a different effect. This gives this person information about the contents of the drug she’s buying, which can be useful information for her.

Of course, when patients use pharmaceutical-grade drugs like oxymorphone, oxycodone, and the like, users know what they are getting. Obviously that different with street drugs.

This guide about drug testing also reminds us that drug tests can help physicians decide if mental health symptoms can be due to mental illness or drug use. For example, patients who have used methamphetamine often have psychotic symptoms. They can be paranoid and have visual and auditory hallucinations.

In the past, when I’ve seen patients with these findings, I’m often relieved to find methamphetamine on their drug screens, because there’s a good chance the clinical signs are all drug-induced, and not a devastating mental disorder like schizophrenia.

These are only a few of the helpful, more big-picture ideas in the ASAM document. I’d like to encourage any physician or provider treating substance use disorder to get and read a copy of the document.

Advertisements

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.

Inmates with False Positive Drug Tests Accused of Taking Suboxone

According to news reports, inmates in Attica, New York, were wrongly accused of using buprenorphine (generic for the active medication in Suboxone and, Subutex). Apparently their urine drug screening system had a glitch, and nearly fifty inmates had these false positive screens. The prisoners, their lawyers, and their families badgered the Department of Corrections to investigate further, and when they did question the drug testing company, the unexpected results were found to be due to lab error. Until the error was acknowledged, inmates received sanctions and punishments including solitary confinement. It took a little over a month to discover the tests were in error, but at least the error was caught and acknowledged.

This is a good example of the lack of credibility addicts and inmates have. If a known addict protests a positive drug screen, much of the time they’re assumed to be lying. It’s not only law enforcement personnel who think this way; treatment center personnel can begin to believe all addicts are lying when they say their drug test results are wrong.

We must remember that no test is 100% correct and there will be false positives (the test shows drug use where none occurred) and false negatives (drug use occurred but wasn’t detected by the test) on screening tests. Granted, the rates of error are fairly low, but if you do enough tests, some addicts will be falsely accused of using drugs that they didn’t use.

That’s why secondary testing is crucial for contested results.

Most drug testing has two parts. The first screening test is quick, cheap, and relatively accurate. Most of the time, this test is sufficient. But in situations where positive tests have major negative consequences for the person being tested, a second, more accurate (and more expensive) test should be offered.

The second test is usually based on gas chromatography. If chain of custody has been maintained, the results of this test meet the legal standard of “beyond a reasonable doubt.” In other words, while no test is 100%, this test is so close that the courts accept it as proof.

At the opioid treatment programs where I’ve worked, many patients claim that their positive screening tests are in error, and they haven’t used the drug in question. That’s when the second test should be offered. However, gas chromatography is more expensive, and the issue becomes who should pay this extra thirty to forty dollars – the treatment center or the patient?

At one treatment center where I’ve worked, staff tells the patient that the second test will be done if the patient requests, but if the test is confirmed as being a true positive, the patient pays the cost of the second test. If the second test does NOT confirm the questioned result, the treatment program bears the cost. Thus, most people who know they’ve used the drug in question don’t request the second test because it’s a waste of their money. And patients who know they haven’t used are understandably eager to have the second test done on their sample, so they can prove their continued abstinence from drugs.

Drug testing is essential in the treatment of addiction, but treatment centers should make sure their tests are done by a certified lab and interpreted by a trained physician if questions arise. Confirmatory testing should be offered as an option to patients who question screening results.

Drug tests and Suboxone (buprenorphine)

Even some treatment professionals and medical professionals have mistaken ideas about drug testing for buprenorphine.

Because it’s a man-made opioid, buprenorphine won’t show as an opiate on a drug screen. It won’t cross-react with tests for oxycodone or hydrocodone. A specific test for buprenorphine must be done in order to detect its presence. In the past, this test was expensive, but now can be added to a drug test fairly cheaply.

I test for buprenorphine because I need to make sure my patients are taking their medication, and haven’t given it or sold it to someone else. Fortunately, I’ve never had a patient to whom I’m prescribing Suboxone have a urine drug screen that didn’t show the medication.  

My patients ask me if the Suboxone I prescribe for them will show up on employment testing, and I answer no, it’s unlikely. Most employers don’t check for methadone, and are even less likely to check for buprenorphine. Employers won’t know unless you tell them you’re on Suboxone. (Methadone, like Suboxone, has to be tested for on a separate test, and won’t show as an opiate.)

Should you tell them? That’s a question you’ll need to answer for yourself. Ordinarily I’m an advocate of honesty, but because Suboxone is usually prescribed to treat opioid addiction, disclosing this information more or less informs them you’ve had a problem with addiction. Is that your employers business? No, I think not, unless it’s a “safety sensitive” job, and even then it’s often not appropriate to tell your employer.

Drug Tests for Patients on Suboxone or Methadone

“Why do I have to do a drug screen? Don’t you trust me?”

Lately a few of my Suboxone patients seem to be questioning the need for drug screens. Some of them resent the tests, and resent paying for them.

So why do I do drug tests?

  • 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 Suboxone, 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 surprises 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.
  • 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.
  • 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 Suboxone should induce them do drug screens. I know if my charts are ever audited by the DEA (unlikely), my state’s department of health and human services, or my state’s medical board (more likely), I want to 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 Suboxone 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 object to screening have had 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.