Reassessing the Role of Routine Urine Drug Screening in Opioid Use Disorder Treatment

Predictors of urine toxicology and other biologic specimen missingness in randomized trials of substance use disorders

BACKGROUND

High levels of missing outcome data for biologically confirmed substance use (BCSU) threaten the validity of substance use disorder (SUD) clinical trials. Underlying attributes of clinical trials could explain BCSU missingness and identify targets for improved trial design.

METHODS

We reviewed 21 clinical trials funded by the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and published from 2005 to 2018 that examined pharmacologic and psychosocial interventions for SUD. We used configurational analysis-a Boolean algebra approach that identifies an attribute or combination of attributes predictive of an outcome-to identify trial design features and participant characteristics associated with high levels of BCSU missingness. Associations were identified by configuration complexity, consistency, coverage, and robustness. We limited results using a consistency threshold of 0.75 and summarized model fit using the product of consistency and coverage.

RESULTS

For trial design features, the final solution consisted of two pathways: psychosocial treatment as a trial intervention OR larger trial arm size (complexity=2, consistency=0.79, coverage=0.93, robustness score=0.71). For participant characteristics, the final solution consisted of two pathways: interventions targeting individuals with poly- or nonspecific substance use OR younger age (complexity=2, consistency=0.75, coverage=0.86, robustness score=1.00).

CONCLUSIONS

Psychosocial treatments, larger trial arm size, interventions targeting individuals with poly- or nonspecific substance use, and younger age among trial participants were predictive of missing BCSU data in SUD clinical trials. Interventions to mitigate missing data that focus on these attributes may reduce threats to validity and improve utility of SUD clinical trials.

Rates and costs of drug testing practices for private payors in the outpatient setting in the United States, 2015-2019

INTRODUCTION

Clinical practice guidelines recommend drug testing patients who are receiving opioids chronically for pain or medication for a substance use disorder (SUD)-particularly opioid use disorder (OUD)-but practices vary due to a lack of consensus on testing frequency during follow-up. This study aimed to evaluate rates and costs of outpatient drug testing practices for patients receiving opioids for chronic pain or medication for an SUD.

METHODS

Using claims data from a large de-identified claims data warehouse, we conducted a retrospective cohort study of chronic opioid, buprenorphine, and naltrexone users between January 2015 and December 2019. We identified two cohorts-chronic opioid medication cohort (CO) and SUD-indicated medication cohort (SUD). We assessed drug testing rates during follow-up using procedure codes and costs using copayment, deductible, co-insurance, and out-of-pocket data.

RESULTS

Among 6,657,515 eligible claimants, 367,118 (5.5 %) received opioids chronically and 73,303 (1.1 %) received an SUD-indicated medication. The cumulative proportion of drug testing during follow-up was similar between cohorts (CO: 36 %; SUD: 35 %), but rate of testing was consistently twice as frequent for the SUD cohort. All cost variables for the first drug test were higher on average in the SUD cohort than the CO cohort except copay: deductible (SUD: $18.54; CO: $7.33); co-insurance (SUD: $10.36; CO: $2.53); out-of-pocket (SUD: $29.39; CO: $10.57); copay (CO: $0.71; SUD: $0.49) (all p < 0.001).

CONCLUSIONS

Overall proportion of drug testing was similar between cohorts, but testing frequency was at least double during follow-up in the SUD cohort. Most cost variables were higher in the SUD cohort. Whether the high cost of drug testing is a barrier to medication use or is associated with treatment discontinuation should be evaluated.

Association of Cannabis Legalization with Cannabis Positive Drug Screening in US Veterans

Background

Although cannabis legalization is associated with increases in self-report cannabis use, biological measures of cannabis use are needed to address potential bias introduced by improved self-reporting of cannabis use in states enacting medical cannabis laws (MCL) and recreational cannabis laws (RCL).

Objective

Quantify the role of MCL and RCL enactment in cannabis positive urine drug screen (UDS) prevalence among Veterans Health Administration (VHA) emergency department (ED) patients from 2008 to 2019.

Design

Staggered-adoption difference-in-difference analysis were used to estimate the role of MCL and RCL in cannabis positive UDS data, fitting adjusted linear binomial regression models to estimate the association between MCL and RCL enactment and prevalence of cannabis positive UDS.

Participants

VHA enrolled veterans aged 18-75 years with ≥1 ED visit in a given year from 2008 to 2019.

Main Measures

Receipt of ≥1 cannabis positive UDS during an ED visit were analyzed.

Key Results

From 2008 to 2019, adjusted cannabis positive UDS prevalences increased from 16.4% to 25.6% in states with no cannabis law, 16.6% to 27.6% in MCL-only enacting states, and 18.2% to 33.8% in RCL-enacting states. MCL-only and MCL/RCL enactment was associated with a 0.8% (95% CI, 0.4-1.0) and 2.9% (95% CI, 2.5-3.3) absolute increase in cannabis positive UDS, respectively. Significant effect sizes were found for MCL and RCL, such that 7.0% and 18.5% of the total increase in cannabis positive UDS prevalence in MCL-only and RCL states could be attributed to MCLs and RCLs.

Conclusions

In this study of VHA ED patients, MCL and RCL enactment played a significant role in the overall increases in cannabis positive UDS. The increase in a biological measure of cannabis use reduces concerns that previously documented increases in self-reported cannabis use from surveys are due to changes in patient willingness to report use as it becomes more legal.

Urine drug testing among Medicaid enrollees initiating buprenorphine treatment for opioid use disorder within 9 MODRN states

BACKGROUND

Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid.

METHODS

We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis.

RESULTS

The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state.

CONCLUSIONS

Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study

OBJECTIVE

The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT).

METHODS

Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections.

RESULTS

Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference.

CONCLUSION

This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.

Utilizing telemedicine during COVID-19 pandemic for a low-threshold, street-based buprenorphine program

BACKGROUND

Changes in federal policy during the COVID-19 pandemic allowing for the use of telemedicine to treat opioid use disorder (OUD) have facilitated innovative strategies to engage and retain people in treatment. Since 2018, the Baltimore City Health Department has operated a mobile street medicine program called Healthcare on The Spot (The Spot) that provides treatment for OUD and infectious diseases. This study describes the transition of The Spot's buprenorphine service to telemedicine during the COVID-19 pandemic and one year treatment retention.

METHODS

Patients actively engaged in care at the time of transition to telemedicine and patients newly engaged in buprenorphine services through telemedicine were included in this descriptive analysis and assessed at one year for retention.

RESULTS

From March 16, 2020 to March 15, 2021, The Spot provided voice-only buprenorphine treatment services to 150 patients, 70.7% (n = 106) male and 80.0% (n = 120) Black; 131 were patients who transitioned from in person services and 19 were newly engaged via telemedicine. 80.7% (n = 121) of patients remained engaged in treatment at one year, 16.0% (n = 24) were lost to follow-up, and 3.3% (n = 5) were deceased. Patients newly engaged via telemedicine were more likely to be female and white than those retained from in person services.

CONCLUSION

The Spot's transition of patients from a street medicine program to telemedicine during the COVID-19 pandemic has implications for future practice. Increased flexibility of service delivery, extended prescription length, and decreased UDT likely contributed to high retention rates and should inform the future structure of low-threshold buprenorphine programs.

Negative Impact of Amphetamine-Type Stimulant Use on Opioid Agonist Treatment Retention in Ontario, Canada

Objective: The objective of this study was to evaluate epidemiological trends of co-use patterns of amphetamine-type stimulants and opioids and the impact of co-use patterns on Opioid Agonist Treatment (OAT) retention in Ontario, Canada. The secondary objective was to assess geographical variation in amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Methods: A retrospective cohort study on 32,674 adults receiving OAT from ~70 clinics was conducted between January 1, 2014, and December 31, 2020, in Ontario, Canada. Patients were divided into four groups base on the proportion of positive urine drug screening results for amphetamine-type stimulants during treatment: group 1 (0-25%), group 2 (25-50%), group 3 (50-75%), and groups 4 (75-100%). A Fractional logistic regression model was used to evaluate differences over time in amphetamine-type stimulant use with urine drug screening results. A Cox Proportional Hazard Ratio model was used to calculate the impact of amphetamine-type stimulant use on retention in OAT and adjusted for sociodemographic characteristics, drug use and clinical factors. Lastly, a logistic regression model was used on a subgroup of patients to assess the impact of geography on amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Results: There were significant differences in amphetamine-type stimulant positive urine drug screening results year-over-year from 2015 to 2020. Significant differences were observed between amphetamine-type stimulant groups with regards to sociodemographic, clinical and drug use factors. Compared to those with no amphetamine-type stimulant use, the number of days retained in OAT treatment for amphetamine-type stimulant users was reduced (hazard ratio 1.19; 95% confidence interval = 1.07-1.17; p < 0.001). Lastly, an adjusted logistic regression model showed a significant increase in the likelihood of amphetamine-type stimulant use in Northern Rural regions compared to Southern Urban areas. Conclusion: There was a significant increase in amphetamine-type stimulant use among individuals in OAT from 2014 to 2020, associated with decreased OAT retention. Research is required to determine if tailored strategies specific to individuals in OAT who use amphetamine-type stimulants can improve OAT outcomes.