Definitive urine drug testing in office-based opioid treatment: a literature review

Direct-To-Definitive Urine and Oral Fluid Test Results for Unscreened and Rarely Screened Drugs in Individuals Applying for Methadone Treatment in 7 U.S. States

The standard protocol in addiction treatment/pain management is to conduct immunoassay screens for major drugs subject to misuse, followed by confirmatory testing of positive results. However, this may miss unscreened or rarely screened drugs that could pose risks, especially to polydrug users. We sought to determine the prevalences of unscreened/rarely screened drugs in a sample of individuals misusing drugs in 7 U.S. states, and to compare the results of urine vs. oral testing for these drugs by direct-to-definitive liquid chromatography/tandem mass spectrometry (LC-MS-MS). The five drugs with the highest prevalences were: gabapentin (16.8%), quetiapine (6.2%), chlorpheniramine (5.3%), hydroxyzine (4.9%), and ephedrine (3.5%). All have clinical significance as indicated by severity of possible side effects, interactions with other drugs, and/or misuse potential. Drugs were generally detected more frequently in oral fluid than urine, but gabapentin was more frequently detected in urine. The prevalences of the included drugs seem high enough, and their clinical significance important enough, to warrant consideration of expanding clinical drug test panels, either by direct-to-definitive testing or the addition of selected immunoassay screens when available. Oral fluid was usually more suitable than urine as the test matrix, given the higher rates of detection in oral fluid for most substances included in this study.

Evaluation of urine drug screen falsification of results among patients with opioid use disorder receiving treatment in a telehealth model of care

INTRODUCTION

As telehealth models for treatment of opioid use disorder (OUD) are expanding, the field does not know the reliability of urine drug screening (UDS) in this setting. The objective of this study is to determine the rate of falsification of UDS testing among patients with OUD in active treatment with buprenorphine via a telehealth provider.

METHODS

This is a prospective cohort study of 899 randomly selected eligible patients, of which 392 participated in the final cohort that the study team used for analysis. The study mailed patients a UDS cup and asked them to return the sample by mail. After the UDS sample was received, a buccal swab was mailed, and the study asked patients to schedule a virtual meeting in which consent was sought and an observed buccal swab was obtained. We evaluated urine for evidence of falsification, and used buccal swabs to genetically match individuals to urine samples.

RESULTS

After exclusion criteria, 395 (52.3 %) of 755 patients who received a UDS kit returned it for analysis prior to knowledge of the study. Of that, 392 samples had sufficient quantity for testing. We determined 383 (97.7 %) to be human urine containing buprenorphine without indication of exogenous buprenorphine addition and with evidence of compliance. A total of 374 patients received a buccal swab kit and 139 (37.2 %) attended the consent/observed buccal swab session. One hundred and thirty-two patients consented and completed the swab under video observation, and 120 successfully sent the swab back to the external laboratory. Of the 120 buccal swabs received, 109 (90.8 %) were a genetic match, 10 (8.3 %) were indeterminate, and 1 (0.8 %) was a genetic mismatch.

CONCLUSIONS

This study of patients treated by a telehealth OUD provider demonstrated a low rate of urine test falsification.

Comparing presumptive with direct-to-definitive drug testing in oral fluid vs. urine for a U.S. national sample of individuals misusing drugs

BACKGROUND

The aims are to compare the results of presumptive drug testing with confirmation of positives vs. direct-to-definitive drug testing, combined with investigation of urine vs. oral fluid as test matrices.

METHODS

Paired oral fluid and urine specimens were collected voluntarily and anonymously from 1098 individuals applying for methadone treatment in 11 clinics across 7 U.S. states. All specimens were analyzed by immunoassay (IA) and liquid chromatography-tandem mass spectrometry (LC-MS-MS).

RESULTS

Confirmed IA prevalences for urine were significantly higher than for oral fluid for 7 out of 10 drug classes - benzodiazepines, cannabis, cocaine, methadone, opiates, oxycodone and tramadol. Drug prevalences by direct-to-definitive LC-MS-MS were either the same or higher than prevalences by confirmed IA. Drug prevalences by LC-MS-MS were higher in urine for two drug classes (cocaine, methadone) and higher in oral fluid for two drug classes (buprenorphine, tramadol), but were equivalent in urine and oral fluid when averaged over all 10 drug classes. Certain drugs of special concern such as heroin and buprenorphine were more frequently detected in oral fluid than urine.

CONCLUSIONS

Urine analysis showed some technical advantage over oral fluid in sensitivity to several drug classes within a confirmed IA testing protocol, but this may be outweighed if there is reason to believe that tampering with urine specimens is a significant problem. Overall drug detection by direct-to-definitive testing was similar for oral fluid and urine, but one matrix may be preferable if there is a particular drug of clinical or epidemiological interest.

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.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.

Polysubstance Use Among Patients Treated With Buprenorphine From a National Urine Drug Test Database

IMPORTANCE

Polysubstance use is a concern for patients treated for opioid use disorder (OUD). While buprenorphine can curtail harmful opioid use, co-occurring use of nonprescribed substances, such as cocaine, methamphetamine, and other opioids, may negatively affect treatment outcomes.

OBJECTIVE

To characterize factors associated with urine drug positivity for nonprescribed substances among patients prescribed buprenorphine.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included patients who had been prescribed buprenorphine and who provided urine specimens for urine drug testing (UDT), as ordered by clinicians in primary care or behavioral health or at substance use disorder treatment centers, from 2013 to 2019. Specimens were analyzed by liquid chromatography-tandem mass spectrometry to assess positivity for several commonly used substances.

EXPOSURES

Buprenorphine prescription.

MAIN OUTCOMES AND MEASURES

Positivity for buprenorphine and several nonprescribed substances. Unadjusted trends in positivity for each nonprescribed substance were compared between specimens that did and did not test positive for buprenorphine. Multivariable logistic regression was used to examine factors associated with positivity; factors included patient age, sex, setting of care, payer, collection year, and census division.

RESULTS

The study included first UDT specimens from 150 000 patients, of whom 82 107 (54.74%) were men and 77 300 (51.53%) were aged 18 to 34 years. Across all specimens, 128 240 (85.49%) were positive for buprenorphine, and 71 373 (47.58%) were positive for 1 or more nonprescribed substances. From 2013 to 2019, positivity rates increased for most substances (eg, fentanyl: from 131 of 21 412 [0.61%] to 1464 of 13 597 [10.77%]). Factors associated with positivity varied widely by substance; for example, fentanyl positivity was highest for men (OR, 1.13; 95% CI, 1.06-1.21), patients aged 18 to 24 years (OR for patients ≥55 years, 0.46; 95% CI, 0.39-0.54), patients living in New England (OR, 1.19; 95% CI, 1.07-1.33), and patients with Medicaid (OR, 1.20; 95% CI, 1.11-1.31), whereas oxycodone positivity was greatest for women (OR for men, 0.84; 95% CI, 0.79-0.89), patients older than 55 years (OR, 1.42; 95% CI, 1.22-1.64), patients living in the South Atlantic (OR, 1.45, 95% CI, 1.33-1.58), and patients with private insurance (OR for Medicaid, 0.78; 95% CI, 0.73-0.84). Patients whose specimens were positive for buprenorphine were significantly less likely to be positive for other opioids (eg, fentanyl: OR for buprenorphine-negative samples, 6.71; 95% CI, 6.29-7.16; heroin: OR for buprenorphine-negative samples, 9.93; 95% CI, 9.31-10.59).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, patterns of nonprescribed substance positivity among patients prescribed buprenorphine varied widely. This study highlights the utility of UDT in public health surveillance efforts related to patients treated with buprenorphine for OUD.

Opioid Exposures Reported to U.S. Poison Centers

OBJECTIVE

Opioid-related deaths are a leading cause of accidental deaths in the United States (U.S.). This study aims to examine the national trends in opioid exposures reported to U.S. poison centers (PCs).

METHODS

The National Poison Data System (NPDS) was queried for opioid exposures between 2011 and 2018. We descriptively assessed the demographic and clinical characteristics. Trends in opioid frequencies and rates were analyzed using Poisson regression. Independent predictors of serious adverse events in opioid exposures were studied.

RESULTS

There were a total of 604,183 opioid exposure calls made to the PCs during the study period. The frequency of opioid exposures decreased by 28.9% (95% CI: -29.6%, -28.1%; p < 0.001), and the rate of opioid exposures decreased by 21.2% (95% CI: -24.7%, -16.9%; p < 0.001). Multiple substance exposures accounted for 48.9% cases. The most frequent age group was 20-29 years (19.3%). Suspected suicides accounted for 34.9% cases. There were 7,246 deaths in our study sample, with 6.8% of cases demonstrating major effects. Hydrocodone was the most frequently observed opioid causing a toxic exposure and naloxone was used in 20.6% cases. Important predictors of a serious adverse event were age, gender, multi-substance exposures, and reasons for exposure.

CONCLUSIONS

Analysis of calls to PCs indicated a decreasing trend of opioid exposures. However, the proportion of SAEs due to such exposures increased. There was a high proportion of intentional exposures and occurred in older age groups. PCs are a vital component of real-time public health surveillance of overdoses in the current opioid crisis.