Charlotte Van Hale, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Rachel Gluck, MD PGY-4 General Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Yi-lang Tang, MD, PhD Associate Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia Addiction Psychiatrist Substance Abuse Treatment Program Atlanta Veterans Health Care System Decatur, Georgia
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Acknowledgments The authors thank Jennifer Casarella, MD, and Karen Hochman, MD, of Atlanta VA Medical Center, and the Department of Psychiatry and Behavioral Sciences, Emory University, for their comments on this article.
Because a screening test has high sensitivity and low specificity, false positives may occur.17,27 Therefore, when a result is in dispute, the use of a high-specificity confirmatory test is often needed (many laboratories have reflex confirmatory testing). However, in the case of diluted urine (urine creatinine concentrations <20 mg/dL), patients should be told the findings are physiologically implausible, and a new urine sample should be obtained.24
Goals of laboratory monitoring
Laboratory monitoring, including UDS and urine buprenorphine levels, is a mainstay of treatment for patients with OUD. The increased use of telehealth has affected how laboratory testing is conducted (Box 240,41). The goal of laboratory testing is to influence treatment and improve patient outcomes. Clinical data such as clinician assessment, patient self-reporting, and collateral information provide essential details for patient management. However, laboratory monitoring is often the most reliable and objective source by which to influence treatment.
Box 2
How telehealth changed laboratory monitoring practices
While delivering therapy via telehealth has been shown to decrease the stigma that surrounds treatment, reduce no-show rates, increase retention in care, improve treatment access for patients who have difficulty commuting, and allow for continuity of outpatient treatment during the COVID-19 pandemic, there are also challenges.40,41 Inducing patients on buprenorphine via telehealth, as well as managing complex treatment cases or repeated failed urine drug screen tests, can be especially challenging. However, treatment standards should be followed as much as possible, and laboratory monitoring as clinically indicated should still be used to improve treatment outcomes.
If needed, patients may be directed to community labs for urine screening and should have results sent to their clinicians prior to the telehealth visit. Complex treatment cases (eg, repeat positive opioid screens, or negative urine buprenorphine screens with comorbid psychiatric conditions) should be handled on an individual basis and in-person appointments may be needed. Video assessment is always preferable to telephone. For patients who are unable to use video and have difficulty maintaining negative drug screens, an in-person visit should be requested.
An increased understanding of recommended laboratory monitoring practices may improve your comfort with OUD treatment and motivate more clinicians to offer buprenorphine, a life-saving and disease-modifying treatment for OUD. Doing so would increase access to OUD treatment for patients to reduce the individual and public health risks associated with untreated OUD.
Bottom Line
Laboratory monitoring, particularly urine drug screens and urine buprenorphine levels, is the most reliable source of information in the treatment of patients with opioid use disorder (OUD). An increased understanding of monitoring practices may improve a clinician’s willingness to offer buprenorphine as an option for therapy and their ability to properly treat patients with OUD.
