Urine Drug Testing in Long-term Opioid Therapy

Abstract

As long-term opioid analgesic therapy has gained increasing clinical and societal acceptance over the past 2 decades, morbidity and mortality related to the misuse of these drugs have increased in lockstep. Hence, monitoring for opioid-related problems, largely through urine drug testing, has become a central component of risk mitigation in long-term opioid therapy. Despite the increasing use of urine drug testing, little has been written about the ethical aspects of its application. In this paper, we analyze multiple aspects of drug testing-rationale for testing, specimen collection, ordering and interpretation, and response to inappropriate test results-through the principlist lens, using the ethical principles of beneficence, nonmaleficence, justice, and autonomy.

Counselors’ Clinical Use of Definitive Drug Testing Results in Their Work with Substance-Use Clients: a Qualitative Study

“…These data suggest that working with denial and incorporating the results of definitive drug testing into treatment in a non-stigmatizing manner may, in some cases, provide the conditions for greater engagement in therapy and enhancing the therapeutic relationship (Kelley et al 2014 ). This last point is particularly noteworthy given that there has been speculation that drug-test results in the clinical setting might unintentionally stigmatize clients and damage the therapeutic alliance (e.g., Reisfield 2014 ; SAMHSA 2011 ). Stigma in the context of SUD can often represent the negative attitudes of healthcare professionals that have clinical consequences for patients (Earnshaw et al 2013 ).…”

“…Counselors’ perspectives of the impact of definitive LC-MS/MS drug testing were consistent with potential benefits outlined in a number of guidelines (e.g., ASAM 2013 ; NIH 2009 ; Gourlay et al 2012 ) including the treatment goals of increasing motivation (Prochaska et al 1992 ), reducing denial (Blume and Marlatt 2009 ; Levin 1998 ), and, by extension, enhancing the therapeutic relationship (Kelley et al 2014 ; Levin 1998 ). They further suggest that counselors and their clients can overcome stigma and other potential obstacles to the therapeutic use of definitive drug testing (Reisflield 2014 ). Though these qualitative results are necessarily preliminary and must be interpreted with caution, they are consistent with previous work suggesting that clinical drug testing can impact treatment decisions and patient outcomes to help optimize patient care (Clancy et al 2013 ; SAMHSA 2011 ).…”

“…These three a priori themes were also built into the clarifying prompts of the semi-structured interview, increasing the likelihood that they would be represented in the data. The fourth theme of potential stigma was not built into the interview but was suggested by the literature (Earnshaw et al 2013 ; Reisfield 2014 ; SAMHSA 2011 ) and emerged from initial reviews of the narratives, as agreed by the two reviewing psychologists. The coding by the two reviewing psychologists based on these four themes was in complete agreement.…”

“…This recent reconceptualization of drug testing is striking given its historical roots in a forensic model, such as in workplace and criminal justice settings (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012 ), and as such may carry with it some stigma that should be considered in clinical and therapeutic contexts (Reisfield 2014 ; SAMHSA 2011 ). In contrast to the forensic use of drug testing with its focus on public safety, such as keeping intoxicated truck drivers off the road, the goal of clinical drug testing is on improving health outcomes of the patient (SAMHSA 2012 ).…”

“…Potential obstacles to drug testing have been acknowledged in the literature, including concerns of stigmatizing clients, burdening the therapeutic relationship, or possible legal consequences for clients (Reisfield 2014 ; Gourlay et al 2012 ; SAMHSA 2011 ). As SUD are already prone to many sources of stigma (Earnshaw et al 2013 ), any investigation of the potential therapeutic impact of drug testing should include consideration of potential stigma and other obstacles.…”