Does urine drug abuse screening help for managing patients? A systematic review

Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol

INTRODUCTION

Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020.

METHODS AND ANALYSIS

We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results.

ETHICS AND DISSEMINATION

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

Psychiatric and non-psychiatric drugs causing false positive amphetamines urine test in psychiatric patients: a pharmacovigilance analysis using FAERS

INTRODUCTION

Immunoassay urine drug screen (UDS) is frequently used in clinical practice for initial screening process, being generally available, fast, and inexpensive. Exposure to widely prescribed drugs might determine false positive UDS amphetamines, leading to diagnostic issues, wrong therapeutic choices, impairment of physician-patient relationship and legal implications.

AREAS COVERED

To summarize and comment on a comprehensive list of compounds responsible for UDS false positive for amphetamines, we conducted a literature review on PubMed along with a comparison with Real World Data from the Food and Drug Administration Adverse Event Reporting System (FAERS) database analysis between 2010 and 2022. Forty-four articles and 125 Individual Case Safety Reports (ICSR) involving false positive amphetamine UDS in psychiatric patients were retrieved in FAERS.

EXPERT OPINION

False positive results were described in literature for antidepressants, atomoxetine and methylphenidate, antipsychotics, but also for non-psychiatric drugs of common use, like labetalol, fenofibrate and metformin. Immunoassays method is usually responsible for false positive results and in most cases mass spectrometry (MS) do not eventually confirm the UDS positivity. Physicians should be aware of immunoassays' limitations and when turning to a confirmatory test. Any new cross-reaction should be reported to pharmacovigilance activities.

Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study

BACKGROUND

Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology.

METHODS

Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus.

RESULTS

Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions.

CONCLUSIONS

A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.

A Descriptive analysis of urine drug screen results in patients with opioid use disorder managed in a primary care setting

BACKGROUND

Urine drug screening (UDS) is commonly used as part of treatment for opioid use disorder (OUD), including treatment with buprenorphine-naloxone for OUD in a primary care setting. Very little is known about the value of UDS, the optimum screening frequency in general, or its specific use for buprenorphine treatment in primary care. To address this question, we thought that in a stable population receiving buprenorphine-naloxone in the primary care setting it would be useful to know how often UDS yielded expected and unexpected results.

METHODS

We present a descriptive analysis of UDS results in patients treated with buprenorphine-naloxone for OUD in a primary care setting over a two-year period. An unexpected test result is: 1. A negative test for buprenorphine and/or 2. A positive test for opioids, methadone, cocaine and/or heroin.

RESULTS

A total of 161 patients received care during the study period and a total of 2588 test results were analyzed from this population. We found that 64.4% of the patient population (n = 104 patients) demonstrated both treatment adherence (as measured by buprenorphine positive test results) and no apparent unexpected test findings, as defined by negative tests for opioids, methadone, cocaine and heroin. Of the 161 patients, 20 results were positive for opioids, 5 for methadone, 39 for heroin and 2 for cocaine. Analysis at the UDS level demonstrated that, of the 2588 test results, 38 (1.5%) results did not have buprenorphine. Of the 2588, 28 (1.1%) test results were positive for opioids, 8 (0.3%) were positive for methadone, 39 (1.5%) for cocaine and 2 (0.1%) for heroin.

CONCLUSION

Given that the majority of patients in our study had expected urine results, it may be reasonable for less frequent urine testing in certain patients.

A Retrospective Cohort Study Examining the Utility of Perinatal Urine Toxicology Testing to Guide Breastfeeding Initiation

OBJECTIVE

National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum.

METHODS

Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use.

RESULTS

Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use.

CONCLUSIONS

Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.

What the lab can and cannot do: clinical interpretation of drug testing results

Urine drug testing is one of the objective tools available to assess adherence. To monitor adherence, quantitative urinary results can assist in differentiating "new" drug use from "previous" (historical) drug use. "Spikes" in urinary concentration can assist in identifying patterns of drug use. Coupled chromatographic-mass spectrometric methods are capable of identifying very small amounts of analyte and can make clinical interpretation rather challenging, specifically for drugs that have a longer half-life. Polypharmacy is common in treatment and rehabilitation programs because of co-morbidities. Medications prescribed for comorbidities can cause drug-drug interaction and phenoconversion of genotypic extensive metabolizers into phenotypic poor metabolizers of the treatment drug. This can have significant impact on both pharmacokinetic (PK) and pharmacodynamic properties of the treatment drug. Therapeutic drug monitoring (TDM) coupled with PKs can assist in interpreting the effects of phenoconversion. TDM-PKs reflects the cumulative effects of pathophysiological changes in the patient as well as drug-drug interactions and should be considered for treatment medications/drugs used to manage pain and treat substance abuse. Since only a few enzyme immunoassays for TDM are available, this is a unique opportunity for clinical laboratory scientists to develop TDM-PK protocols that can have a significant impact on patient care and personalized medicine. Interpretation of drug screening results should be done with caution while considering pharmacological properties and the presence or absence of the parent drug and its metabolites. The objective of this manuscript is to review and address the variables that influence interpretation of different drugs analyzed from a rehabilitation and treatment programs perspective.

Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy

BACKGROUND

Opioid agonist therapy (OAT) is a first-line treatment for opioid use disorder (OUD); however, the efficacy and role of urine drug screening (UDS) in OAT has received little research attention. Prior evidence suggests that UDS frequency reflects philosophy and practice context rather than differences in patient characteristics or clinical need. Therefore, we reviewed the literature on the effect of and recommendations for the frequency of UDS on health outcomes for persons with OUD who receive OAT.

METHODS

We searched Medline and EMBASE for articles published from 1995-2017. Search results underwent double, independent review with discrepancies resolved through discussion with a third reviewer, when necessary. Additional articles were identified through snowball searching, hand searching (Google Scholar), and expert consultation. The Cochrane tool was used to assess risk of bias.

RESULTS

Of the 60 potentially eligible articles reviewed, only one three-arm randomized open-label trial, comparing weekly and monthly UDS testing with take-home OAT doses, met our inclusion criteria.

CONCLUSIONS

Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern.

Utility of Urine Drug Testing in Outpatient Addiction Evaluations

OBJECTIVE

Data examining usefulness of urine drug testing in addiction settings for accurately establishing diagnoses and informing treatment is limited. In this retrospective-cohort study we examined the utility of performing urine drug testing in patients presenting for an outpatient addiction assessment.

METHODS

Urine drug testing and patient-reported substance use history were obtained from the medical record of patients who presented for an outpatient addiction evaluation. Patients who denied use of a substance within the window of detection but tested positive were considered to have misrepresented their use. Differences between patients accurately representing versus misrepresenting their use were evaluated. Sensitivity/specificity of drug tests were calculated from self-report and changes to treatment recommendations and diagnoses assessed.

RESULTS

One hundred and seventy-four patients (mean age = 43.35 ± 15.68 years) were included and the sample was majority male (67%). Ninety-four (54%) patients reported use of a substance within the window of detection. Of 80 patients denying recent use, 14 tested positive (8%). There were no differences in sex (P = 0.78) or age (P = 0.12); referral sources differed significantly between correct and incorrect responders (P = 0.01). Specificity varied between 96% and 99%, while sensitivity had a wider range (17%-87%). Treatment recommendations and diagnoses were altered after review of drug testing results in 1 patient (0.5%). However, in the remainder, all patients were already diagnosed with a severe substance use disorder and had received recommendations to initiate residential/outpatient substance use treatment.

CONCLUSIONS

Among patients completing urine drug testing during outpatient substance use disorder evaluation positive screens alerted providers to undisclosed persistent substance use and potential withdrawal in 8% of the cohort and resulted in a change in diagnoses and/or treatment in 1 patient.

Large Variation in Provincial Guidelines for Urine Drug Screening during Opioid Agonist Treatment in Canada

Urine drug screening (UDS) is commonly used to detect or validate self-reported substance use, particularly when beginning and maintaining opioid agonist therapy (OAT). However, there is currently no summary of the published clinical practice guidelines for UDS in Canada, and no measure of the consistency with which different provinces suggest administering UDS. Therefore, we conducted a policy scan of UDS guidelines, examining the published clinical practice guidelines for each Canadian province and extracting all relevant data in March 2017. Our Canadian guideline and policy scan found that UDS frequency recommendations vary greatly among Provinces for persons receiving OAT for opioid use disorder.

The utility of universal urinary drug screening in chronic pain management

BACKGROUND

A recent systematic review found few studies that assessed the value of urinary drug screening (UDS) in the management of chronic pain. The Pain Management Unit in Halifax, Nova Scotia, has recently implemented tandem mass spectrometry (TMS) UDS for all new patients.

AIMS

To study the prevalence of unexpected TMS UDS results at a hospital-based chronic pain center, to assess which drugs are most likely to contribute to an unexpected result and to assess the clinical utilization of unexpected results by pain physicians.

METHODS

From June 2014 to June 2016, a total of 664 patients with chronic non-cancer pain (CNCP) were seen for initial consult. Charts were reviewed and used to create a database containing sex, age, UDS result, physician, and medication/illicit drug history. For all unexpected UDS results, an interview was conducted with the treating physician to determine its clinical implications.

RESULTS

For the general pain specialists, the overall percentage of patients with an unexpected UDS result was 16.67%. Excluding codeine, at most 4.47% of patients tested unexpectedly positive for a strong opioid. Although eight out of nine physicians found UDS helpful in general, only 29.58% of unexpected results were helpful in the management of their patients and directly influenced their care.

CONCLUSIONS

The prevalence of an unexpected UDS result in patients with CNCP is significant. Most physicians agree that UDS is helpful but in only a limited number of cases did the unexpected result provide helpful information that significantly influenced patient care.

Filling the gap between lab and clinical impact: An open randomized diagnostic trial comparing urinary ethylglucuronide and ethanol in alcohol dependent outpatients

BACKGROUND

Efforts aimed at reducing alcohol-related harm include early detection of risky drinkers as well as detection of early relapse in patients with alcohol dependence. Ethyl glucuronide (EtG) has been proven to be a reliable biomarker for the detection of recent drinking; however, no randomized, diagnostic trial to date has tested its impact on drinking outcomes. The aim of this study was to assess, in a randomized design, the implications of EtG screening on alcohol outcomes, compared to screening with a low sensitivity biomarker such as ethanol.

METHODS

Alcohol dependent outpatients were randomized to either 24 weeks of continuous screening with EtG or ethanol. Patients were aware of screening methods and results. After 24 weeks, all participants were screened with EtG. Self-reports were also gathered. A logistic regression compared the rate of EtG positive results at study end between groups. Generalized estimating equations evaluated the descending monthly rate of EtG positive patients in the EtG group.

RESULTS

A total of 162 patients were randomized. During the study period, the ethanol group showed less patients with positive screens (19/64 (29.7%) vs 58/98 (59%)). After 24 weeks, the EtG group showed a greater number of patients having a negative screening test compared to ethanol subjects when they were all screened with EtG (5/62 (8.1%) vs 13/39 (33.3%)). A significant decrease in the rate of EtG positive patients was found for the first three months of the study.

CONCLUSIONS

Routine screening with EtG seems to reduce drinking and improve abstinence rates in alcohol dependent outpatients.

Patients' Knowledge and Attitudes Towards Regular Alcohol Urine Screening: A Survey Study

BACKGROUND

Despite its wide implementation, there is a paucity of data supporting the effectiveness of regular alcohol urine screening (RAUS) in maintaining abstinence. This study aims at investigating if RAUS serves other purposes, what attitudes patients display towards it, and patients' technical knowledge about basic screening notions.

METHOD

We conducted a cross-sectional survey among adults with alcohol dependence, attending outpatient alcohol-dependence treatment. It aimed at investigating patients' attitudes and beliefs towards RAUS, and technical notions of alcohol urine screening. For attitude assessment, we adapted the Drug Attitude Inventory (DAI-10) to the field of alcohol urine screening. Internal consistency, test-retest reliability, and concurrent validity were evaluated for the adapted questionnaire.

RESULTS

In all, 128 patients completed the questionnaire. Patients rated RAUS as high. The DAI-10 mean score was 7.2 (SD = 3.6). Internal consistency analysis revealed a Cronbach alpha of 0.718. Test-retest reliability evaluation yielded an intraclass correlation coefficient of 0.932. The score of a single Likert-type question about overall perceived value was 8.5 (SD = 2). Their correlation with mean DAI-10 score was of r = 0.254, with P = 0.009. Apart from relapse prevention, patients frequently reported other functions such as showing professionals and family members that they do not drink, or having a closer contact with professionals. A majority of patients believed alcohol use goes undetected after 48 hours from last ingestion.

CONCLUSION

Regular alcohol screening is highly valued by alcohol outpatients. It seems that apart from relapse prevention, other functions related to therapeutic alliance building, social desirability, and impression management also play a key role.

Chronic opioid therapy urine drug testing in primary care: prevalence and predictors of aberrant results

BACKGROUND

Urine drug tests (UDTs) are recommended for patients on chronic opioid therapy (COT). Knowledge of the risk factors for aberrant UDT results could help optimize their use.

OBJECTIVE

To identify primary care COT patient and opioid regimen characteristics associated with aberrant UDT results.

DESIGN

Population-based observational.

SAMPLE

5,420 UDTs for Group Health integrated group practice COT patients.

MEASURES

Group Health database measures of patient demographics, medical history, COT characteristics, and UDT results.

RESULTS

Thirty percent of UDTs had aberrant results, including prescribed opioid non-detection (12.3%), tetrahydrocannabinol (THC; 11.2%), non-prescribed opioid (5.3%), illicit drug (excluding THC; 0.6%), non-prescribed benzodiazepine (1.7%), and dilute (4.8%). Adjusted odds ratios (95% CI) of any aberrant result were higher for males than females (1.24 [1.07, 1.43]), patients with versus without prior substance use disorder diagnoses (1.42 [1.17, 1.72]), and current smokers versus non-smokers (1.50 [1.30, 1.73]). Odds ratios were lower for patients aged 45-64 (0.77 [0.65, 0.92]) and 65+ (0.40 [0.32, 0.50]) versus patients aged 20-44 and for patients on long-acting opioids only (0.72 [0.55, 0.95]) or long-acting plus short-acting (0.67 [0.54, 0.83]) versus short-acting only. Adjusted odds of prescribed opioid non-detection were lower for patients aged 45-64 (0.79 [0.63, 0.998]) and 65+ (0.44 [0.32, 0.59]) versus patients aged 20-44, for those on 40-<120 mg daily morphine-equivalent dose (0.52 [0.39, 0.70]) or 120+ mg (0.22 [0.11, 0.43]) versus <40 mg, and for patients on long-acting (0.35 [0.21, 0.57]) or long-acting plus short-acting (0.35 [0.24, 0.50]) opioids (versus short-acting only); and odds ratios were higher for patients with versus without prior diagnoses of substance use disorder (1.70 [1.31, 2.20]).

CONCLUSIONS

In this primary care setting, results were aberrant for 30% of UDTs of COT patients, largely because of prescribed opioid non-detection and THC. Aberrant results of almost all types were more likely among patients under the age of 45. Other risk factors varied across aberrancies, but commonly included current smoking and prior substance use disorder diagnosis.