Adjusting Drug Testing Protocols

COVID-19 - Adjusting drug testing protocols 

Adjusting Drug Testing Protocols 

While urine drug testing is generally an important part of substance use disorder management, during a public health emergency, access to life-saving addiction treatment should not be conditional on urine drug testing. This section provides guidance to addiction treatment providers and programs regarding adjusting drug testing protocols during the COVID-19 pandemic. The goal is to balance the utility of obtaining data from a drug test against the risk of COVID-19 virus exposure to patients, laboratory staff, and clinic staff/providers.

Drug Testing Guidance Download

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Updated: 6/30/20

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Reopening

While many places across the country are starting to relax physical distancing restrictions, the COVID-19 pandemic is not over. Communities and treatment programs across the country remain at risk for increasing population prevalence over time.

In areas or settings where community spread of COVID-19 virus is occurring, it may be appropriate to provide continued access to on-going medications for addiction treatment without attending their treatment facility or having drug testing done. Urine drug testing is only one piece of information in the comprehensive treatment of opioid use disorder. Other information obtained from patients can be used to adequately inform treatment strategies such as self-reported use of substances, timing of refill requests, checking of the state prescription monitoring program, and other indications of improvements (housing, employment, relationship status). Requiring patients to present to a health care facility to provide urine samples for urine drug testing may be more harmful than beneficial. Patients may unnecessarily increase their risks of exposure to the COVID-19 virus through their travel to or presence in health care facilities. Providers and programs should carefully weigh the risks and benefits of urine drug testing, both for the patient and for community public health and particularly for patients who are stable.

As the COVID-19 crisis continues to evolve and unfold, several circumstances in clinical practice may arise in which the benefit of having results from drug testing outweighs the risk of COVID-19 exposure and transmission. For example, drug testing may be of greater importance in the management of:

  • Patients with known or suspected diversion of medication for substance use disorders.  
  • Patients who present in-person to a treatment facility with symptoms and signs of intoxication.
  • Patients with a self-reported or otherwise identified overdose.
  • Patients with significantly unstable opioid and/or other substance use disorders.

Clinicians should also consider other ways of obtaining information about medication adherence and patient safety and stability that would supplement or inform medication management decisions and reduce reliance on drug testing.

  • If feasible for both the patient and provider, daily virtually observed self-administration of  addiction treatment medications via a video telehealth platform may be an alternative.
  • With patient consent, involve loved ones or other family members in helping support the patient and their medication adherence.
  • Increase the frequency of phone or other telehealth contacts with patients who may be struggling.
  • Reduce the amount of medication provided at a time and consider the use of alternate medication delivery options if increased in-person visits poses too high a risk in terms of COVID transmission.
  • Patient self-reported substance use.
  • Frequent query of the prescription drug monitoring program.

If drug testing is resumed or continued in a treatment facility, consider the staffing, supplies, and protocols needed for ensuring this can occur while still adhering to infection control recommendations. This includes:

  • Having sufficient PPE for staff collecting samples.
    • This may include face masks, face shields, gowns, and gloves, depending on resources, environmental context, and transmission risk.
  • Using low-cost testing metrics to identify sample alteration or dilution (e.g. urine creatinine and pH) to avoid need for observed sample collection.
  • Workflows that maintain 6 feet physical distance between staff and patients.
  • Ensuring space large enough to allow for 6 feet physical distance between patients who may be waiting to provide a sample.
  • Sanitizing collection areas between each patient.

Because it will take longer per patient to collect a sample when following procedures to prevent COVID-19 transmission, providers will need to prioritize the circumstances and the patients for whom this procedure is needed. Drug testing for routine purposes is not recommended at this point.

Unexpected Drug Test Results in Patients Treated with Opioid Agonist Medications

If drug testing is resumed or continued and there is an unexpected negative result for the patient’s opioid agonist medication and respective metabolite, the provider should consider:

  • The accuracy of the OUD diagnosis. Does the patient have an opioid use disorder at a level of severity for which agonist medication is needed?
  • Reasons for a negative result could include:
    • The patient took more than prescribed and ran out of medication significantly before providing the sample for testing.
    • The patient is on such a low dose or taking so little of the medication that he/she is not effectively absorbing sufficient medication to permit detection at the threshold of detection for the test.
    • This may be a particular issue with daily buprenorphine formulations.  
    • The sample that was tested did not actually belong to the patient.
    • Medication diversion.
  • The provider should have a forthright conversation with the patient to try to determine the reason for the negative test.
  • The provider should consider adjusting the patient’s treatment plan based on the results of this conversation and test result.
  • The provider should strongly consider whether the patient would benefit from direct observation of medication dosing (including via telehealth).
  • If the provider strongly suspects or has evidence of diversion despite conversations with the patient and adjustments to the treatment plan, the provider has a responsibility to cease continuing a medication which is no longer effectively treating the patient’s OUD.
  • The provider should strongly consider whether the patient’s OUD would be more effectively treated with a different medication or formulation.

Collecting specimens for drug testing outside the treatment facility: For patients for whom it is deemed necessary to have drug testing done as required for ongoing medication treatment, it may be appropriate to have this testing done outside of the normal protocols. Any alternative testing protocol should minimize contact between staff and patients and minimize the strain on local laboratory services. A recent study examined different body fluid samples taken from patients with COVID-19 for presence of coronavirus RNA. All 72 urine samples tested negative. However, the CDC still does recommends taking precautions with collecting any bodily fluid samples because they do not yet have a complete picture of how transmission occurs. Strong consideration should be given to the availability of personal protective equipment (PPE) and the need to ration these scarce resources.

Drug testing from home: The COVID-19 pandemic and related social distancing practices may go on for many months. Treatment providers should explore options for drug testing at a distance such as using oral fluid-based tests and/or home breathalyzer tests monitored via telehealth.