Opiate Project ECHO™: Unexpected Urine Drug Test Results Mentor Session

1. NEOMED TEMPLATE Ohio Opiate Project ECHO™: Expanding Access to Medication-Assisted Treatment Mentor Session: Unexpected Results in Urine Drug Testing

2. MENTOR ECHO:GLOBAL Learning objectives • Evaluate patients for appropriate referral to medication-assisted treatment (MAT) using a collaborative, person-centered approach • Describe effective treatment strategies for prescribers using MAT in office-based settings • Recognize the level of care needed for complex patients in MAT programs utilizing team-based warm handoffs during transitions of care • Educate patients, families and other community/ social supports about the emotional and behavioral aspects of opioid use disorders in order to reduce stigma

3. Session learning objectives • Review the most common reasons for unexpected results in urine drug testing • Discuss strategies for managing unexpected results in urine drug testing

4. Why Presume innocence? • It is a respectful stance—what if the unexpected results were yours? Or your child’s? • Treatment providers are NOT THE POLICE • Urine drug test is only one piece of the puzzle • It allows you to ally with the patient AGAINST the disease of addiction • “I trust you. I don’t trust your disease.” • “Your disease wants to keep you sick—it wants you dead.”

5. Look for evidence of Recovery-related activities • 12-step meeting attendance • Sponsor, phone list, home group? • Actually working the steps? • Attendance at counseling/IOP/PHP sessions • Attendance at medical/psych appts • Living in a sober house/going to sober places • Prayer, meditation, exercise • Housing/employment/school going well • Honesty, Openness, and Willingness (H.O.W.)

6. If my patient is telling the truth… • What are the other plausible explanations? • How likely are the other plausible explanations? • Ask open-ended questions • How did that get in there? • What can you tell me? What happened? • Consider next steps •  Frequency of visits?  amount of prescription? •  Frequency of testing? Testing for different drugs? • Random or observed testing? • Test oral fluid or hair or sweat? • Refer to a higher level of care?

7. What you should see on the UDT • Temperature is in the appropriate range • Cr is within normal limits • Confirmation testing has been completed • Bup and Norbup are both present • All other substances of abuse are absent

8. What you MIGHT see on the UDT: Most common scenarios • UDT screen is - but patient acting strangely • UDT screen is + but confirmatory is - • UDT is tampered with (Temp, Cr, other…) • UDT + for bup, - for norbup • UDT is - for bup, - for all other drugs of abuse • UDT is - for bup, + for other drugs of abuse • UDT is + for bup/norbup, + for MJ • UDT is + for bup/norbup, + for uppers • UDT is + for bup/norbup, + for benzos • UDT is + for bup/norbup, + for other opioids

9. 1. UDT screen is -but patient acting strangely • Consider: • drugs not picked up by routine screening • medical causes (blood sugar, infection, seizure, head injury, etc.) • psych causes (mania, psychosis, panic, etc.) Strategy Notes: • Do you know what your screen tests for? • Can you test by a different method (oral fluid, hair, etc)? • Have you called the lab for more info? • Can you check vital signs?

10. 2. UDT screen is + but confirmatory is - • Beware the unconfirmed test due to false + • Re-do the test and confirm it • Or set up urine screening with “reflex confirmation” Strategy Notes: • Have a list of common drugs that cause false + • Do not make big clinical decisions based on screening test—get it confirmed

11. 3. UDT is tampered with (Temp, Cr, other…) • Temperature strips are helpful • Dilute samples may point toward tampering • https://urineluck.com/ Strategy Notes: • What is the patient afraid that you will find out? • Call it out! • Ask for new sample • Dye in the toilet

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13. 4. UDT + for bup, - for norbup • Usually indicates that patient has dropped a small crumb of bup tablet or dipped bup film into the urine cup • Lack of metabolite means drug did not pass through this patient’s liver Strategy Notes: • Explain the finding nonchalantly • “I would appreciate the truth, I can help you so much more if you tell me the truth.” • “If this continues, I may need to taper and discontinue…”

14. 5. UDT is - for bup, - for all other drugs of abuse • This is odd, especially if patient insists they are taking the bup • “rapid metabolizer”? • Could be they are diverting it to buy something you don’t test for (i.e. fentanyl, kratom, K2/spice, bath salts) Strategy Notes: • “This doesn’t make sense…” • Send out the test and ask for specific drug that you suspect • Consider testing at different times of the day

15. 6. UDT is - for bup, + for other drugs of abuse • More clearly indicative of diversion to buy other drugs Strategy Notes: • Where is the recovery-related activity? • Invoke the state law— “Bup prescribers are closely watched. This doesn’t look good…” • “I cannot continue to prescribe in this situation…”

16. 7. UDT is + for bup/norbup, + for MJ • If they admit to smoking or taking MJ, what else was mixed in with it? • Bup doesn’t treat MJ Use Disorder Strategy Notes: • Quantitative levels are very helpful in this situation • Readiness to change for each drug may differ • Can you find other meds to cover the things that MJ helps with?

17. 8. UDT is + for bup/norbup, + for uppers • If they admit to smoking or taking illicit or prescribed stimulant, what else was mixed in with it? • Bup doesn’t treat Stimulant Use Disorder Strategy Notes: • Quantitative levels may be helpful in this situation • Readiness to change for each drug may differ

18. 9. UDT is + for bup/norbup, + for benzos • If they admit to smoking or taking illicit stimulant, what else was mixed in with it? • Bup doesn’t treat Benzo Use Disorder Strategy Notes: • Always walking the tightrope in this situation • Document risk of overdose/death with this ongoing combination • May need higher LOC • May need to taper med and switch to other MAT

19. 10. UDT is + for bup/norbup, + for other opioids • Current dose may be inadequate • Patient may be taking only a small part of the Rx and diverting the rest Strategy Notes: • Pregnancy test • Has the bup dose been optimized? (up to 24mg in Ohio with addiction consult) • If yes, do you need to refer for methadone or naltrexone or higher LOC?

20. If you still can’t figure it out… • Encourage truth-telling and emphasize “safe space” of treatment • Give it time—active addiction will always catch up with the patient • Call the toxicologist at the specific lab for help • Consult a colleague and consider a formal second opinion • Write up the case for the MAT ECHO 

21. references • The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine, 56 pages, 2017 • https://www.asam.org/resources/guidelines-and-consensus-documents/drug-testing • Drug Testing: A White Paper of the American Society of Addiction Medicine (ASAM), 116 pages, 2013 • https://www.asam.org/docs/default-source/public-policy-statements/drug-testing-a-white-paper-by-asam.pdf • TIP 63, SAMHSA, 2018