All right, so I think I will get started. I'll make a few brief introductions about the webinar overall, and then I'll introduce our speaker. So welcome to our first webinar in the series, Testimony from the Trenches, Innovations in Clinical Practice. I'm John Lepley, President-elect of the American Osteopathic Academy of Addiction Medicine. And this webinar really came to fruition due to some dedicated work of members of our education committee. So I definitely would like to note Elise Wessel, Adam Scioli, and Max Pavlak for their hard work in bringing this together. I definitely also want to note Judy Pfeiffer for keeping us all in line and on track. And I am going to give Nina Vidmer credit for our great title, Testimony from the Trenches, although none of us can really remember who came up with the title. These webinars are around the topic of buprenorphine treatment for opioid use disorder. And these first four webinars are intended to, in some ways, challenge the status quo of how we provide buprenorphine treatment really over the past 20 years. For this webinar, our speaker will provide a brief didactic session, and then I will attempt to moderate an orderly and thoughtful discussion about the content that has been presented. The presentation will be recorded, but the discussion that follows will not. The discussion session is not necessarily intended to be a Q&A of our speaker. Rather, we do want to hear from attendees and membership about the topic at hand, how they approach this particular topic, and what they do in their practice. Please be kind to each other and our invited speaker. To keep it orderly, we will ask that you raise your hand, and then we will unmute you and ask you to make your comments about the topic. I will show my cards a little bit by saying that tonight's speaker and I are a bit like-minded on the topic, and I definitely do admire her dedication to exploring problems in our country around drug policy, mass incarceration, and racial disparities with respect to access to addiction treatment. So without further ado, I am going to introduce Dr. Utsa Khatri. She is an assistant professor of emergency medicine at the Icahn School of Medicine at Mount Sinai. She has a secondary appointment at the Institute for Health Equity Research Department of Population Health Science and Policy. As a health services researcher, Dr. Khatri is interested in improving access, outcomes, and equity with regard to the health and healthcare of structurally marginalized populations. Her ongoing projects focus on the healthcare of individuals and communities affected by mass incarceration and those affected by substance use disorders. Dr. Khatri practiced as clinically as an attending emergency physician at Mount Sinai Hospital and at Elmhurst Hospital. Dr. Khatri received her medical degree from George Washington School of Medicine and Health Sciences. She has trained in emergency medicine at the University of Pennsylvania, where she served as chief resident. She completed the National Clinical Scholars Program at the University of Pennsylvania, and she received a master's degree in health policy research. She is also a former Fulbright scholar, and she is going to speak with us today on the topic of urine drug testing in opioid use disorder treatment. And with that, I will turn the presentation over to her. Thanks so much, Dr. Loepple. And thanks everyone for joining us this evening. As Dr. Loepple mentioned, I'm hoping this leads to a discussion, and I'm really interested in hearing from all of you. So let me share my screen. Dr. Loepple, can you give me a thumbs up if you can see my slide? Okay, great. So this didactic will be brief. We're gonna be talking about reconsidering the routine use of urine drug testing in opioid use disorder treatment. I have no financial disclosures or conflicts of interest to declare, and neither does Dr. Loepple. So our objectives are threefold this evening. First, we are going to discuss both the harms and benefits from the perspective of the patient of routine urine drug testing and office-based treatment for opioid use disorder. Then we'll go over some of the literature on this practice. And then finally, I'd like to start a discussion on some alternative approaches to the routine use of urine drug testing. But before I begin, I wanted to start with a patient's story. I am an emergency clinician, but I have a strong interest in addiction medicine, and I have practiced at a clinic providing treatment for opioid use disorder. And so this is my patient, Fred. And while the uncertainty of the COVID-19 pandemic was overwhelming the country, Fred felt really optimistic about his future in a way that he had never had during his 50 years of using drugs. I had started him on buprenorphine through a telehealth visit just one week before the stay-at-home order was issued in our city. A couple weeks later, we had transitioned to telehealth, and I had a follow-up visit with him. He reported mild cravings during that visit over the phone. I asked him if that had triggered him to use opioids, and he excitedly proclaimed, no, doc, my urine is clean. I will bring it to you wherever you want. Now, if this visit had occurred in the clinic in the pre-COVID era, I likely would have conducted a urine drug test, and it likely would have been negative. We would have spent the entire visit reinforcing his clean urine results. I would have completely missed an opportunity to engage in the conversation that actually occurred over the phone, one where Fred expressed that despite his abstinence, he was still really struggling. His goals for recovery were to be more physically active and to be a present father and grandfather, neither of which he felt like he had yet achieved. Without the result of the urine drug screen assuming its role as the centerpiece of our visit, Fred and I instead spent the visit talking about how to break down these barriers that were preventing him from achieving his goals. And I know I'm not alone, and that many clinicians, including many of you on this call today, were forced to really change your practice quite abruptly during the early months of the COVID-19 pandemic, whether that meant being transitioned to a telehealth service, whether it involved having less frequent visits than you felt comfortable with, or whether it meant foregoing lab and urine testing, all of us were forced to re-examine our practice at providing treatment for opioid use disorder. My colleague, Dr. Aronowitz, and I were both practicing in Philadelphia at the time, and we wrote a perspective piece in the Journal of Substance Abuse Treatment of re-imagining addiction care without the reflexive urine drug screen. Now, before we talk kind of about the benefits and harms of the urine drug screen, I think it's really important to give a little bit of history on the origins. So the urine drug test was developed in the 1960s. This article on the top panel there is actually from JAMA from 1966, describing this novel technology that allowed clinicians to detect different drugs in urine testing. And it was primarily used in methadone treatment programs in the 1960s. At the time, it was quite expensive, and it was also pretty error-prone. And so there was a lot of discussion on how to utilize this technology and how to improve it for accuracy. But it was really President Nixon who, during the time, rapidly expanded the urine drug testing program, primarily focusing on veterans returning from Vietnam who had been exposed to a tremendous amount of stress and who were also coming back with lots of untreated substance use disorders. In 1987, under President Reagan, the urine drug testing program expanded beyond the military to include testing federal government employees. And then in 1991, there was a Congress passed an act that required regular urine and drug testing for all what they called safety-sensitive employees. And this was after a couple of very high-profile accidents that actually led to some fatalities around transportation workers who were impaired while at work. And I point all of this out to say that it was really this time period, this culture where drug use and substance use disorders were criminalized. President Nixon famously declared a war on drugs. And it was in this setting and in this context that the use of the urine drug test rapidly expanded to beyond just the methadone treatment programs, but into other parts of healthcare and the workforce. So let's talk about some of the potential harms of the urine drug test. First of all, in my opinion, I think it has a great potential to harm the clinician-patient relationship. It sends a message of mistrust. We often ask our patients how they're doing, if they've used drugs, how they're doing with their medications, but we look to the urine for the real answer. It also compounds this hierarchy that we know exists in clinical medicine, but especially exists in addiction care. And lastly, it aligns the clinicians and the medical team with other systems, systems that are penal in nature, that seek to punish, to catch, to criminalize acts. And using similar methods to do so aligns us away from a therapeutic relationship and more to one that patients really fear us and fear what we can do to them in their recovery. They, of course, can also be very traumatic. And this is especially true for a lot of patients who have substance use disorders, who also have overlying histories of sexual assault, criminal justice involvement, and violence. And so this has led some programs to think about how they can develop trauma-informed urine drug screens. And lastly, it incentivized patients to falsify. If their care and their relationship with their addiction treatment provider really hinges on them having a urine that is deemed acceptable, it really, you know, if they do end up using drugs, it really gives them a reason to falsify their sample. But of course, there are benefits of the urine drug test as well, and that's why it's existed in addiction care for so long. For some patients, and some patients, not all patients, but some patients do report that the urine drug test can be motivating, knowing that they are expected to produce one, knowing that the results will be shared with their clinician. Some people report that this motivates them to continue in their recovery. Additionally, some of these results may be required by non-medical agencies. A lot of our patients are involved in the criminal justice system. Others have certain obligations with different departments of human services, and these agencies do require documentation of certain treatment plans. And so it might be required, not for your medical care, but for your patients' interactions with these systems. It can also help clinicians when they are worried about diversion. And by this, I mean, if you are worried that your patient is not taking the buprenorphine as you're prescribing, the urine drug test can help you decide if that's really the case. It also can help us identify patients who need additional support. We devise treatment plans for our patients without having other tools and practices that we employ routinely. We may not know when they're struggling, when they require higher levels of care or when they require changes to the regimen that we've outlined. And lastly, in this era, it can also help patients know what they're exposed to. We all know that there's a contamination of the entire drug supply, especially bifentanyl. A lot of patients are exposed inadvertently to drugs that they did not intend to use. And so in some cases, the results of the urine drug screen can help patients know what drugs they were exposed to. So next, I just wanted to go over the literature in this space, and this shouldn't take too long because there really isn't much out there. This first paper here by Julie DePuy was published in Drug, Alcohol, and Dependence in 2014. And the aim of this study was to summarize the evidence pertaining to the efficacy of the urine drug screen for medical management. So the team conducted a systematic review. They looked at clinical trials, quasi-randomized observational studies, and looked at where the main outcome was the medical management or consequences of management for patients related to the urine drug screen. They found eight studies that met the inclusion criteria. And when they reviewed the quality of the studies, they deemed it to be poor. And what they concluded was that there were very few studies that have assessed the value of the urine drug screen in managing patients. And due to the poor quality, these studies are not sufficient to demonstrate the interest of carrying out these tests. And what they recommend is additional studies. So a few years later, another group published a review in the International Journal of Drug Policy. And this one was slightly different in that this group sought to examine the frequency of urine drug screen. So rather than just looking at the use overall in urine drug testing, this group was looking at articles that specifically looked at timing and frequency. And again, they reviewed over 60 articles that were potentially eligible, and they found that met their criteria, which was a three-arm randomized open control trial. And this study looked specifically at patients who were using methadone treatment and compared weekly and monthly urine drug screens. And again, overall, their conclusion was that there was insufficient evidence on the effectiveness and the impact of the urine drug screen. And this is the most recent and last study that I'll go over. This one was published actually just last month in September of 2021. And this is the one study that's probably most relevant to your practice. And what this group did was they looked at a stable population of patients who are receiving buprenorphine naloxone in a primary care setting. And they wanted to know how many patients and for how many visits where there was a urine drug screen was there an unexpected result. And they defined unexpected result by two categories. One, either a test that was negative for buprenorphine and patients who were being prescribed buprenorphine or a test that was positive for other drugs, other opioids, methadone, cocaine, or heroin. And what they found was that both at the patient level and at the urine test level, most of the results were expected. There were very few proportions of the test and patients who were stably managed where there were unexpected results. And they concluded given these results, it may be reasonable for less frequent urine testing in certain patients. And so what do the guidelines say on urine drug testing? ASAM has released a clinical guideline on the appropriate use of urine drug testing in clinical addiction medicine. It's a very long, but interesting document. And what they describe is that given the lack of evidence and research in this topic, they really rely on expert opinion to give these guidelines. And what they recommend is that drug testing should be used to monitor recent substance use in all addiction treatment settings, but that it should only be one of several methods used. And the test shouldn't be interpreted in the context of other indicators, either self-report or collateral indicators. And if you're interested in reading more or getting some iconographics on their recommendations, you can go to asam.org and they really break down the recommendations for urine drug screen by different treatment settings and for different patient populations. And so when we think about going from the research to the guidelines to what actually happens in clinical practice, there are a few things to think about. I think ultimately it's really a combination of self-report and urine drug testing that we have to rely on. We can't rely just on the urine drug test. And we have to think of some validated ways to measure patient report. I think it's reasonable to think about random testing rather than routine testing every visit for patients, especially once they're stable on their medications. But we also have to remember that when we, anytime we think about making something random at our discretion, it introduces a huge potential for provider bias. When do you decide as a clinician and which of your patients do you deem untrustworthy that you are going to subject them to a random drug test? Another thing to consider, which is more well-described in the cocaine literature, but is contingency management. Are there certain patients that you care for who would be in that category of patients who are motivated by the urine drug testing? And how can you employ principles of contingency management in conjunction with the urine drug test in their care? The fundamental question is how do we assess our patient's goals? And is complete abstinence really in line with all of their goals? I think the overarching goal that we have as providers for our patients is that patients who have substance use disorders, including opioid use disorder, are able to limit their use to the point that they can fully engage with other parts of their lives. And this doesn't necessarily mean complete abstinence for all substances for all patients. And so it's important to have these discussions with our patients on what their goals are and how we can support them in achieving those goals. And of course, we lack tools to really gauge patient experience. We know patients drop out of treatment. We don't know how to predict which patients are going to drop out of treatment, really because we don't have ways to measure their experience under our care. And so with that, I just wanted to throw up some discussion questions that I'm hoping we can go over. I would like to hear kind of your personal opinions on the role of the urine drug test. What's influenced this opinion? When do you find it helpful? When do you find it harmful? Why do you utilize it? Is it because you find it helpful to your patients or is it because this is just how things have always been done without ever questioning the practice? I'm also really interested in hearing what happened during COVID, if anyone's changed their practice and what happened when we went back into the clinics. Did you go back to screening everyone if that's what you were doing before or did you change your practice? Are there barriers? Are there institutional barriers or barriers at the level of your clinic that would limit you from being able to more liberally utilize the urine drug test? And then what are the patient-centered considerations? How does this affect your relationship with your patients? And more importantly, how does it affect their outcomes in addiction care? These are the resources which will be made available online. And with that, I will stop sharing. Thank you very much for that great presentation. My pleasure. Thanks for having me.

webinar

buprenorphine treatment

urine drug testing

clinician-patient relationship

patient outcomes

ASAM guidelines