Vol. 9: Shall I get a urine test before you see this person?
No thanks, we don't need it today.
There are many things that happen in drug treatment settings that we don't stop and think too hard about. That bothers me. Routinely putting scripts on hold to ‘encourage’ attendance is definitely in that category. It drives me nuts.
Routine, unthinking, urine drug screening is on the list too.
So, this paper in Drug and Alcohol Dependence caught my eye.1
It is a cross-sectional study based in the United States that aimed to work out the association between providers that used a lot of urine drug screening (UDS) and long-term retention in treatment. Good idea. They used the National Drug Abuse Treatment System Survey (NDATSS) which is, in their words, "a nationally representative, longitudinal study of operational characteristics and treatment practices of outpatient substance use treatment programs". It's been gathering data in waves since 1988 and this study used the data collected in 2016-17. They looked at all those opioid treatment programs (OTPs) that give out methadone and the main outcome was the proportion of people at each OTP who remained in continuous treatment for at least a year.
In total there were 150 OTPs. Here’s the breakdown in terms of what they did with urine drug screening:
27% did not do randomised or observed UDS.
15% used observed UDS a lot.
28% used randomised UDS a lot.
31% used both randomised or observed UDS on ≥90% of people.
This reflects the fact that providers in the US do seem to have a lot of leeway to set their policies. There are one heck of a lot of numbers in the results of this paper - to the extent that it becomes very challenging to pick out nice succinct messages and interpret the findings.2
But, overall, while it is messy with confidence intervals sliding around all over the place, the findings do show one thing clearly: those services that do a lot of urine testing (randomised and observed) have poorer retention at one year. It’s less easy to be certain on other categories of testing as they didn’t hit statistical significance.
We need to be very careful here.
These are associations, we don’t know about causation, and it could quite easily be a marker of underlying policies and approaches to people who use drugs.
It seems to me that the US has a more punitive system than we experience in the UK - after all, some clinics can discharge people for testing positive. That horrifies me. But we are delusional if we think we are not awash with similar subtexts in the UK. There are still clinicians who use positive drug screens as a weapon against people who use drugs: You need to test negative or there will be consequences. Often, that even means reducing their dose rather than discharging, or some other ‘privilege’ is withheld. It’s rarely stated so baldly, it might be alluded to, and yet it sits there festering in the privacy of the consultation room. Ask any service user and I bet they can tell a tale on those lines.
We do need to pay attention to the impact of urine testing. Let's remember, retention is critical. The authors make the case that retention in treatment - as per their main outcome - is a reasonable proxy marker for treatment success and I'm inclined to agree. (It's another reason why putting scripts on hold is so egregious and, if I may get all sociological, an act of symbolic violence.) Urine testing could well be pushing in the wrong direction but we rarely stop to question it - the 2017 UK Guidelines show very little in the way of critical thought around this.
Now, I’m not suggesting that there is no case for urine drug testing.3 Yet, one only has to look at the (extremely short) list of other medications and conditions where we test for compliance and concordance. It’s almost non-existent. I read a draft editorial this week that suggested we should consider testing for anti-hypertensive drugs in people who are treatment-resistant before they are referred to specialist clinics.
Can you imagine having that consultation with your doctor?
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Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Drug and Alcohol Dependence. 2024 Feb;255:111067. https://doi.org/10.1016/j.drugalcdep.2023.111067
I have experienced some regret in using this study for the post as the results are verging on impenetrable in the detail. I have fiddled with various ways to present them - and they are all horrible and make this post hundreds of words longer. So, I’ve gritted my teeth and gone for the simple messaging.
And, I’m talking about ongoing monitoring here. Initial assessment, particularly of someone unknown to services, is a different kettle of fish.