US: Some opioid use disorder patients spike drug tests with buprenorphine

There are a number of potential reasons a patient might tamper with a drug test

Some patients prescribed buprenorphine for opioid use disorder (OUD) appear to be spiking their urine drug tests with the medication to mimic results suggestive of adherence, a new study in JAMA Psychiatry suggests.

The study examined about half a million urine test results from Millennium Health, a large national lab. Specifically, these results were from patients prescribed buprenorphine and whose doctors ordered definitive drug testing. Nearly 8% of specimens were suggestive of spiking.

The study aimed to identify characteristics associated with patients spiking their drug tests with their own treatment medicine. Spiked specimens were more likely to be positive for non-prescribed opioids and more likely to be collected in primary care settings.

Spiking suggests that treatment is not working. Little remains known about the issue of patients cheating on their drug tests, the study authors said.

“This study has created more questions and need for research than answers, as all good observational studies do,” lead researcher Jarratt Pytell, M.D., an addiction medicine specialist, told Fierce Healthcare.

Identifying urine spiking can be done by looking at the ratio of an opioid agonist, norbuprenorphine, and buprenorphine in the specimen. But detection requires definitive drug testing, conducted with highly sensitive clinical laboratory methods. Immunoassay, point-of-care tests cannot detect spiking, the study noted.

There are a number of potential reasons a patient might tamper with a drug test; perhaps they are involved with the criminal justice system and their living in a community is contingent on the test, or they are afraid of getting kicked out of a clinic. “The spiking is a symptom but it’s really indicative of something else going on,” Pytell said. 

Clinicians who detect spiking must reassess and adjust a patient’s treatment plan. Instead of threatening the patient, clinicians should take the opportunity to develop a therapeutic relationship and earn that person’s trust by asking what can help them. If a patient is not ready to take medications, clinicians can consider harm reduction alternatives, Pytell said.

“The knee-jerk should not be abandonment,” he said. Instead, clinicians should “open the door and figure out exactly what I can do to help you.”

“If we can improve the overall care and bring that person out of that state of despair, a state where they might want to do this, then the spiking will go away,” Eric Dawson, co-author of the study, echoed in an interview.

The study comes amid rising overdose deaths and the recent elimination of the X-waiver, making it easier for clinicians to treat OUD with medications like buprenorphine. The findings are clinically significant and highlight the need for additional research and best practices tailored to care settings. The study does not make recommendations on whether spiking should be screened for nor how often.

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