Referral to and Engagement in Substance Use Disorder Treatment After Aberrant Urine Drug Test Varies by Substance Detected

Urine drug tests (UDTs) are recommended when patients are prescribed long-term opioid therapy (LTOT). Positive results can lead to opioid discontinuation, but substance use disorder (SUD) treatment patterns after discontinuation have not been studied. Researchers examined a cohort of 600 Veterans Administration patients (300 with and 300 without prior SUD diagnoses) who discontinued LTOT—169 had discontinuation triggered by an aberrant UDT—to compare subsequent treatment referral and engagement based on the substance that led to discontinuation. Patients with SUD treatment within one year prior to opioid discontinuation were excluded.

• In the year following discontinuation, 43% of patients were referred for SUD treatment and 20% engaged in a new SUD treatment episode.
• In adjusted models, patients testing positive for cocaine were more likely than patients testing positive for drugs other than cocaine to be referred for SUD treatment (adjusted odds ratio [aOR], 3.32) and engage in SUD treatment (aOR, 2.44) .
• Patients testing positive for cannabis were less likely than patients testing positive for drugs other than cannabis to be referred for SUD treatment (aOR, 0.44) and engage in SUD treatment (aOR, 0.42).

Comments: While a retrospective chart review cannot capture the nature of SUD treatment-related patient-clinician interactions after an aberrant UDT, the data suggest that SUD referral and uptake vary by substance found on urine testing. Cocaine-positive UDTs appear to reflect more significant SUDs requiring treatment from a provider (referral) and patient (uptake) perspective. The evolving legal status of cannabis, its potential pain relief and/or opioid sparing properties, and low patient interest in SUD treatment referral and entry raise questions about cannabis testing policies during LTOT.

Joseph Merrill, MD, MPH

Reference: Nugent SM, Dobscha SK, Morasco BJ, et al. Substance use disorder treatment following clinician-initiated discontinuation of long-term opioid therapy resulting from an aberrant urine drug test. J Gen Intern Med. 2017 [Epub ahead of print]. doi: 10.1007/s11606-017-4084-0.