In areas or settings where community spread of COVID-19 is occurring, it may be appropriate to provide con- tinued access to pharmacotherapy for addiction without requiring patients to present to a treatment facility or provide a sample for drug testing. This may be particularly true when supplies of appropriate personal protective equipment (PPE) for staff and patients are limited.

Requiring patients to present to a health care facility to provide samples for drug testing may be more harmful than beneficial. Patients may unnecessarily increase their risks of exposure to the novel coronavirus through their travel to or presence in health care facilities. Without adequate PPE, laboratory and other staff may be at in- creased risk for coronavirus transmission as they interact with patients providing specimens.

Clinicians and programs should carefully weigh the risks and benefits of drug testing, both for the patient and for community public health. As always, it is prudent to avoid ordering tests the results of which will not change a patient's management.

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

Clinicians should also consider other ways of obtaining information about medication adherence and patient safe- ty 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 or early in their treatment.
• Reduce the amount of medication provided at a time and consider the use of alternate medication delivery options if increased in-person visits pose 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.
  • including face masks, face shields, gowns, and gloves, depending on resources, environmental con- text, and transmission risk.
• Using low-cost testing metrics to identify sample alteration or dilution (e.g. urine creatinine and pH).
• Reducing or eliminating the use of 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.

If drug testing is resumed or continued and the testing reveals 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.
  • The patient is sharing their medication with another person in need of treatment.
  • 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 neces- sary to have drug testing conducted as a requirement for ongoing medication treatment, it may be appropriate to have this testing done outside of the treatment facility. Any alternative testing protocol should minimize contact between staff and patients and minimize the strain on local laboratory services.

According to the CDC, viable and infectious COVID 19 can be found in both urine and stool samples of infected individuals. Precautions should be appropriately taken when working with these body fluids. In addition, as it is known to be spread through respiratory droplets, care should be taken when working with saliva specimens as well. At this time, the CDC provides no guidance on routinely pre-testing patients for the COVID-19 virus who are giving a saliva sample.

Drug testing from home: The COVID-19 pandemic and related physical 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.

• The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine (Part 4 discusses considerations for testing matrices other than urine, including oral fluid).  https://www.asam.org/Quality-Science/quality/drug-testing

• Wang W, Xu Y, Gao R, et al.  Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA. Published online March 11, 2020. doi:10.1001/jama.2020.3786

• Peng L, et al. SARS-CoV-2 can be detected in urine, blood, anal swabs and oropharyngeal swabs specimens. J Med Virol. 2020 Apr 24  https://doi.org/10.1002/jmv.25936