Opioid Use Disorders, Medication-Assisted Treatment, and the Role of the Laboratory

Roger L. Bertholf, PhD; Gary M. Reisfield, MD

Disclosures

Lab Med. 2017;48(4):e57-e61. 

In This Article

Abstract and Introduction

Abstract

Urine drug testing is an essential component in the evaluation and management of individuals with opioid use disorders, including those on buprenorphine or methadone maintenance therapies. Notwithstanding its centrality in adherence monitoring, studies have shown that clinicians have important knowledge deficiencies regarding the ordering and interpretation of drug tests. In this review, we discuss the scope and frequency of testing, the advantages and disadvantages of immunoassay- (presumptive) and liquid chromatograph-mass spectrometry- (definitive) based techniques, indications for definitive testing, medical necessity, and other considerations. Optimal use of urine drug testing depends on collaboration between clinicians and laboratory scientists.

Introduction

The United States is in the midst of the most important opioid epidemic in its history. In 2015, more than 20,000 Americans died from prescription opioid-related overdoses,[1] bringing the total number of prescription opioid deaths in this generational epidemic to more than 200,000. Moreover, in 2015, 12,000,000 Americans misused prescription opioids, 2,100,000 were past-year initiates of prescription opioid misuse, 2,000,000 had a prescription opioid use disorder, and 822,000 initiated treatment for a prescription opioid disorder.[2] Of those who misused prescription opioids, about one third received their opioids by prescription from a single physician.[2]

In recent years, increased availability, high purity, and relative low cost have made heroin an increasingly prevalent opioid of abuse. Since 2012, heroin has been responsible for more deaths than any other single opioid.[3] In 2015, there were nearly 13,000 fatal heroin overdoses. Of those who used heroin in 2015, 72.1% were also past-year misusers of prescription opioids.

The U.S. Food and Drug Administration has approved buprenorphine, methadone, and naltrexone for the management of opioid use disorders. Evidence indicates that their long-term use is associated with better outcomes than opioid discontinuation or psychological therapies alone.[4]

Urine drug testing (UDT) is a standard component in the care of those in treatment for, and recovering from, opioid use disorders, including those receiving medication-assisted treatment with methadone or, in office settings, buprenorphine or naltrexone. Its purpose is to verify both that the patient is adherent with prescribed medications and abstaining from other drugs that could complicate treatment.

Unlike many common laboratory tests, however, UDT requires knowledge and training to order and to interpret correctly. Several studies have demonstrated that physicians have poor UDT interpretive skills.[5,6] Hence, collaboration between the clinician and the laboratory scientist is essential to optimal use of these diagnostics.

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