Cover: Drug Toxicology Testing Requirements

Drug Toxicology Testing Requirements

Published Dec 21, 2023

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Research Brief

Mandate that providers of medication treatments for opioid use disorder (OUD) conduct at least six drug screens from patients to guide treatment planning.

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and opioid overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
Yes
No
No

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
Yes
No
OUD Treatment Retention
No
Yes
No
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
Yes
No
Affordability
No
Yes
No
Equitability
Yes
No
No

Summary of Expert Comments

  • The panel expects minimal yet negative impacts across all four outcomes because testing may deter patients from treatment and be used by providers as grounds for treatment discharge.
  • The panel expects this policy will exacerbate disparities due to inequitable implementation as a punitive measure, the history of systemic racism associated with drug testing as surveillance and grounds for punitive consequences, and disproportionate treatment dropout and low-quality treatment among populations who already experience disparate outcomes.
  • The general public views toxicology testing as a standard aspect of care; experts expressed concern that toxicology testing could be used punitively in practice.
  • Frequent toxicology testing may be feasible and affordable when used appropriately (i.e., to guide treatment planning rather than discharge patients). However, this policy also depends on political environment, provider willingness to conduct testing, availability of resources for testing, and paying for testing at scale.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Some patients may also be motivated by the opportunity to provide negative toxicology results. “No effect so early in treatment”
Little-to-no
(selected)
Unlikely to impact initial engagement. May depend on whether toxicology tests are used as a punitive measure or one that guides dynamic treatment planning. “Is drug screening used to catch patients and dismiss [them] from practice, or is it to guide intensity of therapy and only 1 measure of treatment success?”
Harmful Frequent punitive toxicology tests cause many people who use drugs to avoid treatment, including those who might otherwise engage with treatment. Drug testing results can also be used by providers to stop treatment. “While there can be ways to couple drug use screening with person-centered care and incentives, the traditional approach has been punitive, reducing treatment engagement, and used to discharge patients”

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Provider use of toxicology results to guide treatment planning and inform shared decisionmaking with patients could lead to increased treatment retention. “As part of a thoughtful clinical treatment plan and conducted with the right clinical posture and therapeutic rapport, this [drug testing] could potentially be a tool to maintain treatment retention”
Little-to-no
(selected)
Usefulness to treatment planning of knowing how patients are responding is counterbalanced by patient dropout and discharge due to toxicology testing. Net-neutral impact on retention over six months. “I think providers feel toxicology testing gives them another tool to help clients. But it's clear it can also be a deterrent to clients who fear the consequences of a positive test. I've heard many stories about treatment programs discharging clients for positive tests. This does not increase retention and could decrease it”
Harmful Frequent punitive toxicology tests cause many people who use drugs to leave treatment (including those who might otherwise remain), especially if patients do not feel trusted. Toxicology testing also can be used by providers to discharge patients with positive results from treatment. “Patients often tell me that the constant imperative to provide urine, often observed by a staff member or recorded on camera, is a huge disincentive to remaining on treatment”

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Toxicology testing could facilitate treatment planning and patient-provider conversations about substance use. Frequent negative toxicology results could motivate patients to not use opioids. “Drug use is often hidden by patients, and unless they are able to talk about it, it would be hard to achieve remission. Being faced with urine results helps to open that conversation. Also, some patients would decide to not use, so as not to come up positive on a [toxicology] screen”
Little-to-no
(selected)
Depends on whether toxicology tests are used as a punitive measure or one that guides dynamic treatment planning. Net-neutral impact given variable implementation. “While the toxicology [testing] can increase [the] likelihood of early treatment termination due to [a] client leaving or being discharged, ... there can be some benefits IF the testing results are used in a therapeutic manner”
Harmful Negative impacts on treatment engagement and retention will translate into negative impacts on remission. Patients may be disheartened by the intrusiveness of testing and receiving positive test results, leading to continued opioid use. “Punitive policies set up the expectation for abstinence as the only version of treatment success and this unreasonable definition can lead to disengagement in services, escalating use, and overdose”

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Toxicology testing will facilitate effective treatment planning, which will reduce the likelihood of overdose among those retained in treatment. Testing may also identify those unintentionally exposed to fentanyl. “Identifying individuals who continue to use opioids will help guide treatment. Improved treatment will reduce the overdose rates of persons in treatment”
Little-to-no
(selected)
Do not expect this policy to impact population-level opioid overdose mortality given the small size of the population who will be retained in this kind of treatment. “Less opioid use reduces risk of opioid overdose death for these patients, but the small percentage of those with OUD who are engaged in [opioid treatment program] methadone treatment means that even great success amongst these patients will not have a large effect on the per capita rates of overdose related to opioids”
Harmful Negative impacts on treatment engagement and retention will translate into negative impacts on overdoses, especially when drug supply is contaminated. “Attrition from treatment as a result of the invasiveness of urine drug testing likely contributes to mortality”

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Public is more accepting of infringements on autonomy for people who use substances (due to stigma). Public also views toxicology testing as a common and effective part of substance use treatment. “This is another policy where the framing is potentially important, but the public seems to more readily accept such requirements for individuals with substance use problems than for other groups where individual freedom might be a stronger consideration”
Moderate Not appropriate for the state to mandate toxicology testing. Some members of the public may disagree with cost and complexity of policy, and frequent testing could serve as a barrier to improving treatment access. “Mandating urine toxicology to guide treatment planning seems like an overreach for a state policy. There is no clearly defined evidence base for exactly how to use and how not to use drug toxicology testing and this is a method employed by the criminal legal system to monitor criminalized people who use drugs. States should stay out of these types of clinical mandates unless there is clear and compelling evidence to set these requirements”
Low Disagreement with the invasiveness involved. “This is extremely invasive and likely not to be liked by the general public”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Already a routine part of care in many settings and systems. “Because it is a common feature of treatment, UDS [urine drug screening] is widely available for implementation in this context”
Moderate
(selected)
Sustainability depends on budgets and austerity. Implementation varies by political environment, who is paying, provider willingness, and availability of resources needed for testing. “There is increasing recognition of the costliness both of testing and of staffing that has raised concerns of effectiveness, which brings in the question of sustained feasibility in times of limited budgets and austerity”
Low Difficult logistically to monitor and enforce. “Sounds very challenging. So many different tests (different vectors, different companies). Who is paying for the tests? Might need a new structure for reporting, unless billing based”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High N/A N/A
Moderate
(selected)
Frequent toxicology testing at scale is expensive but not cost-prohibitive considering potential benefits for OUD treatment when used correctly. Exact costs depend on type of tests and who is paying. “Costly tool, given it is not a necessity for all patients' effective MOUD treatment. Ideally, it is implemented on a patient-centered basis, and used to engage patients in discussion about their drug use and what they want from treatment, rather than as a punitive tool”
Low Frequent toxicology testing at scale is expensive and without clear benefit. Also potential for exploitation of policy in billing practices. “Urine drug testing is enormously expensive to Medicaid. Especially considering the lack of evidence as far as more intensive versus less intensive approach”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High Could increase equity compared with current standard care if standardized and implemented objectively. “May actually increase equity [because it] would take some implicit bias out of how often people are tested”
Moderate Potentially reduces disparities in treatment engagement and retention. Depends on how it is implemented and enforced. “This policy might reduce disparities in treatment initiation and retention, but reducing these outcomes among people with OUD will increase health disparities between the OUD population and other groups”
Low
(selected)
Concerns about likely inequitable implementation as a punitive measure by race, gender, and age; and history of systemic racism associated with treatment approaches that involve surveillance, drug testing, and punitive consequences. Treatment dropout and low-quality treatment resulting from the policy would be more likely among populations currently with disparate outcomes and most in need of treatment (e.g., patients who would have difficulty with finding frequent transportation to office/facility for testing). “Given the prevalence in healthcare of racism, gendered bias, and ageism, UDS is very likely to be used inequitably in MOUD [treatment] and [exerts] a negative effect on health outcomes for people of color, women, and younger people for whom it is used”

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