Urine Drug Screening as Adjunct to History Taking During Intake in Addiction Services

Dear Sir,

Patients coming for addiction treatment services commonly hide their drug use. This could be a challenging issue as it may have implications for the management (whether a person is actually using the substances or not, whether to start a particular medication like naltrexone, whether the patient has been doing well on the treatment, or whether the patient has been taking the previously prescribed medication, and other similar considerations). Urine drug screening can be a useful complementary tool during the intake in addiction services to clarify certain scenarios and bring clarity of diagnosis, management, and intent of the patient, especially when a trusting and non-hostile therapeutic relationship has not been yet established. Urine drug screens (UDSs) have short turnaround and reporting times (sometimes within half an hour) and have the advantage of being quick and fairly reliable. ¹ We describe some situations from clinical practice when urine screen would be a useful adjunct to intake assessment.

A UDS can help confirm stated abstinence from substances of abuse. If the UDS comes positive, then feedback can be given to the patient, attempting to elicit the possible reasons for the same and enabling them to reflect again on the last date(s) of use. People knowingly or unknowingly “forget” or feel coerced to report abstinence due to familial, social, or therapeutic pressure. Reflecting upon an unanticipated positive test in a non-judgemental and non-confrontational manner may help refresh the memory and bring the patient and therapist to the same page. An action that is largely punitive is likely to shear away the developing trust, and minor deception in the information provided to the treatment provider may be ignored for the continuation of treatment. However, clear and firm consequences may be discussed beforehand (before the test) to encourage honesty (e.g., if inpatient treatment is contingent on positive test outcomes).

Another scenario is when a person claims to be using substances while the UDS comes negative. It may so occur when the individual would like certain medications (like opioids) to be prescribed or has an agenda to be considered as having a substance use disorder and seek admission in a treatment facility (possibly to avoid difficult life circumstances outside the therapeutic environment). Concerns of potential diversion can be better addressed by screening for medications like buprenorphine given for opioid substitution treatment. Herein too, an amicable discussion with the substance “user” might help to elicit the cause for reporting substance use when the drug screen is negative.

Thus, one could use UDSs selectively or randomly during intake interviews for addiction services. One should be cognizant of potential false positive and false negative reports, ² issues surrounding an unadulterated collection of samples, and the availability of reasonably accurate testing methods. In select sensitive circumstances, repeat testing or testing using very specific methods (like spectrometry or high-performance liquid chromatography) can be used. Nonetheless, carefully directed UDSs and empathetic utilization of their results can lead to better-directed care of individuals with substance use disorders.