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Guest Editorial: One of These Things Is Not Like the Others

Stephen A. Martin, MD, EdM, FAAFP, FASAM

This guest editorial is part one of a two-part series on drug testing.

Over the past decade, addiction practice in America has been slowly evolving from an abstinence-based to a low-threshold model. For opioid use disorder (OUD), low-threshold models deliberately make it easy to start and continue life-saving buprenorphine or methadone.1-4

Yet we continue to drug test in nearly the same ways as before, seemingly oblivious to the internal inconsistency embedded in this practice.5 Drug testing, derived from an abstinence-based model, is poisoning the well of low-threshold practice.

How we got here isn’t a pretty story, and an understanding of contemporary care requires historical inquiry, skill in clinical reasoning, and an awareness of one of medicine’s tragic flaws: hubris.6-8 Below is a short summary, hewing closely to the original sources and framed as a set of rhetorical questions.

  1. Is drug testing grounded in a history of patient-centered care?

Current drug testing practices are directly derived from methadone programs in the 1960s for people on parole; if not abstinent, they returned to jail (Table 1). Similar high stakes continue for current patients—from revocation of take-home dosing to added impossible requirements to program termination—who “fail” their drug test.9

Table 1: A very short history of how drug testing became standard practice:

1952   Finding and surveilling people in West Berlin with opioid use disorder10

1961   California parole program based upon drug testing to verify complete abstinence11

1968   Drug testing is embedded in early methadone treatment12

1971   Negative opioid test required for any soldier to return from Vietnam13

1971   Negative opioid test required for methadone treatment and parole from DC jails14

1972   Vietnam testing model applied to emergent Opioid Treatment Program (OTP) regulations15

2025   Same general approach as 1952

  1. Do we have evidence that testing:

Provides patient benefit?

A PubMed search for “drug testing and substance use disorders” results in only one related meta-analysis. This 2014 publication found 8 studies from 1994 to 2012, none of which address outpatient care of opioid use disorder; 7 of the 8 scored “Poor” on GRADE criteria and one scored “Fair.”16

Causes harm?

Testing can not only harm patients in care, it can discourage people from entering care at all.17-19 Below are just a few examples of harm, affecting both individuals and entire demographic groups.

  • Eating a salad with poppy seeds led to loss of parental custody20
  • Termination from treatment leads to increased drug overdose deaths21
  • Racial inequities in how often drug tests are ordered22
  • Self-discharge from an American OTP after seeing humane methadone care in Australia23
  • A patient’s loss of housing and return to use because of misinterpreted confirmatory testing24

Changes clinical management (in a nonabstinent model3)?

The residue of abstinence-based thinking represented by drug testing obscures the progress patients are actually making in reducing chaotic use and improving the quality of their lives.25,26 Changes in management, should they occur, are most likely to be harmful as clinicians and staff fixate on labs instead of a person.

  1. Do we have necessary elements for testing and clinical decision-making?

Judicious testing requires the following: an evidence-based indication where results constructively change clinical management; informed consent; evaluation of pretest probability; requisite confirmatory testing; and interpretation readily and correctly conducted by the clinical end user.6

Sound clinical decision-making requires each of these aspects.27-29 Yet after 50 years of use, drug tests are still incorrectly ordered, interpreted, and applied on a routine basis. Please see the 2024 ASAM presentation, “Drug Testing in Substance Use Disorder Treatment: Does It Help or Hurt?” where I discuss the above elements in further detail.30,31

  1. Should US use of drug testing be reconceived in the context of low-threshold care?

Please find excerpts from recent publications here (bold my emphasis):

“To truly advance OUD treatment, we must move beyond urine drug tests and prioritize metrics that reflect the diverse outcomes that patients value, including physical, emotional, and social well-being.”32

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“In this regard, an imposed urine test can be understood as an implicit threat that, should the result be positive, the person in treatment may incur negative consequences such as excluding or interrupting OAT. Such an approach is not in the interest of the person, that of their family or wider society. Therefore, it appears unethical to impose urine tests on a vulnerable population that is particularly likely to disengage from healthcare.”33

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“Patients have a right to refuse any treatment service, including drug testing. Treatment programs should not attempt to coerce patients into participating. Admission and discharge decisions should not be based solely on drug test results or refusal of drug testing. Drug test refusal should be well-documented, along with the clinician’s interpretation of its clinical relevance for the given patient.”34

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“[A]t Arud Centre for Addiction Medicine, a leading Swiss clinic, all patients.… are not required to participate in counseling, or subjected to drug tests, or punished if they relapse and use illicit substances...
…“This wouldn’t be possible in a system which is very restrictive, where people are getting kicked out of the program or disappearing because they can’t comply with the regulations and rules. I think we would lose a lot of patients. They would die.”35

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“Urine drug testing is mandatory in 8 out of 23 [studied] countries; Spain requires it only in prisons.”36

What should we do differently?

While addiction medicine is evolving rapidly in some ways, our specialty still carries remnants of the abstinent-based model. Drug testing without deliberate clinical decision-making does not coincide with a more humane, low-threshold model.

While these practices are wound down, each of us can act today to reduce patient harm. Here are some practical ways to do less harm with drug testing:

  • Test as infrequently as possible
  • Do not test randomly
  • Use only confirmatory (LC-MS) testing (which is covered by Medicaid)
  • Use oral fluid (saliva) direct to LC-MS testing as the default
    • Drug detection is “similar for oral fluid and urine testing”37
    • Patients prefer saliva-based testing38
    • Samples are readily collected in clinic room, not a bathroom
    • The experience of urine-based testing can negatively affect patients9,39-41
  • If using urine-based testing, do not observe the patient’s test
  • Test only for the substance of interest: methadone or buprenorphine
  • Make clear you are only looking for the treatment medication
  • If patients want testing—or are required to have it—use the above principles as possible

John Hughlings Jackson (1835-1911), a pioneer of neurology, astutely diagnosed medicine’s harmful inertia: “It takes 50 years to get a wrong idea out of medicine, and 100 years a right one into medicine.”42 People with substance use disorders cannot wait any longer for us to get this wrong idea, harmful drug testing, out of medicine.

Stephen Martin is a family and addiction medicine physician providing rural primary care, as well as a professor in the Department of Family Medicine and Community Health at UMass Chan Medical School. He is lead or senior author of publications in the BMJ, JAMA, Lancet, Annals of Internal Medicine, the Journal of Addiction Medicine, Substance Use & Addiction Journal, and the American Journal of Public Health. His email address is stmartin@gmail.com.

 

 

References

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