Clinical and Public Health Considerations in Urine Drug Testing to Identify and Treat Substance Use

ABSTRACT

Background: To expand appropriate use of substance use testing, practitioners must increase their knowledge of the appropriate methodology, scope, and frequency. Yet, there is a current lack of accepted guidelines on clinical testing to identify and treat substance use. Objectives: This article (1) conveys the importance of substance use testing as a clinical and public health response to trends of prescription drug abuse and increased access to medical and commercialized marijuana; (2) summarizes central features of the rapidly evolving science and the practice of patient-centered substance use testing in a clinical setting; and (3) provides recommendations that balance costs and benefits and serve as a starting point for appropriate testing to prevent, identify, and treat substance use disorders. Methods: The author conducted a search of peer-reviewed and government-supported articles and books in electronic databases and used her own knowledge and clinical experience. Results: The author makes recommendations for determining the methodology, scope, and frequency of testing in each stage of care based on clinical considerations and methodological factors. Conclusion/Importance: Integrating sensible substance use testing broadly into clinical health care to identify substance use, diagnose substance use disorders, and guide patients into treatment can improve health outcomes and reduce the costs of substance use and addiction. No single testing regimen is suitable for all clinical scenarios; rather, a multitude of options, as discussed herein, can be adapted to meet a patient's unique needs. Ultimately, the practitioner must combine patient-specific information with knowledge of test technologies, capabilities, limitations, and costs.

KEYWORDS:

• Urine drug testing
• substance use disorder
• substance abuse
• diagnosis
• treatment
• recovery
• immunoassay
• chromatography-mass-spectrometry

Notes

1 Low-complexity urine drug tests are not infallible due to the subjective nature of interpretation of the visual cue and operator error. Operator error stems from failure to attend to test device expiration, time elapsed, test validity measures, control lines, the counterintuitive nature of some devices where a “line” indicates a presumptive absence of the analyte, and other condition-based human error (e.g., poor light, misunderstanding of faint signals, etc.).

2 Although POCs may involve either immunoassay or chromatography-mass spectrometry-based technology, in this article, “POC” only refers to tests utilizing immunoassay technology.

3 Practitioners can assess parent drug and metabolite using the patient as his own control over time to determine whether metabolism of specific drugs has changed. An immunoassay would not show such a change or identify multiple drugs within a class.

4 Immunoassays do not detect all drugs that a patient might be using, such as Tramadol and many forms of benzodiazepines, so they many not provide enough accuracy to support safer prescribing precautions.

5 It is advisable for the practitioner to be aware of a patient's use of any substance - at any concentration - that, when combined with a prescription medication under consideration, is likely to yield an undesirable pharmacological effect. Even low concentrations of an analyte in the patient's specimen indicate that the patient has access to the substance detected and has a history of using it, both of which can affect prescribing decisions.

6 In some instances, it may be appropriate to test more frequently to determine every instance of substance use and establish abstinence. In such a case, testing should be done no more than three times per week with either immunoassay or chromatography-mass spectrometry tests based on clinical considerations.

7 If every instance of use is vital to establish abstinence or provides information necessary for a treatment plan, testing may be done more frequently. In such a case, testing should be done no more than three times per week with either immunoassay or chromatography-mass spectrometry tests based on clinical considerations.

Additional information

Notes on contributors

Andrea G. Barthwell

Andrea G. Barthwell, M.D., F.A.S.A.M., is the founder and Chief Executive Officer of the global health care and policy consulting firm EMGlobal LLC and Director at Two Dreams Treatment Centers. President George W. Bush nominated and the United States Senate confirmed her to serve as Deputy Director for Demand Reduction in the Office of National Drug Control Policy (ONDCP) from January 2002 to July 2004. As a member of the President's sub-cabinet, Dr. Barthwell was a principal advisor in the Executive Office of the President (EOP) on policies aimed at reducing the demand for illicit drugs. Dr. Barthwell received a Bachelor of Arts degree in Psychology from Wesleyan University, and a Doctor of Medicine from the University of Michigan Medical School. Dr. Barthwell is a past president of the American Society of Addiction Medicine and in 2003, Dr. Barthwell received the Betty Ford Award, given by the Association for Medical Education and Research in Substance Abuse.