(45) Urine Drug Screening in a Telehealth Setting for Opioid Use Disorder Treatment

Background &

Introduction: Routine urine drug screening (UDS) to test for illicit substance use and adherence to buprenorphine treatment is commonplace in addiction treatment settings. However, there is little consensus about testing schedules and how to respond to results, leading to great practice variation and inconsistencies even within the same clinical settings. The COVID-19 pandemic instigated federal policy changes that allowed for expanded telehealth-based opioid treatment (TBOT). Multiple studies have found that TBOT may be associated with improved patient outcomes (eg, increased retention, decreased medically treated overdoses) relative to in-person OBOT. Two studies documented decreases in UDS frequency concurrent with the COVID-19 pandemic and the corresponding expansion of TBOT, likely driven by a reactive decision to reduce patients’ exposure to COVID-19 as opposed to a proactive change in protocols. Amid the rapid and widespread adoption of TBOT, there is an urgent need for rigorous studies exploring the feasibility and characteristics of UDS in remote care settings. The objective of this study was to assess the feasibility of UDS, patterns of UDS administration, and rates of unexpected results (ie, negative for buprenorphine, positive for other opioids) among a cohort of patients treated for OUD in a TBOT setting.

Methods: This observational cohort study was conducted between January 1, 2021, and December 6, 2022, and included patients with opioid use disorder treated in Ophelia, a TBOT treatment platform in 14 states. Data analysis was performed from January to March 2023. The number and percentage of patients with UDS within 30, 90, and 180 days of intake were assessed, grouped by adherence to clinical protocols. Associations were assessed between baseline characteristics and UDS completion and opioid positivity in first 30 days using chi-squared tests. Baseline and 180-day follow-up UDS results were compared using McNemar tests.

Results: Among 3395 patients (mean [SD] age, 38.2 [9.3] years, mostly male [54.1%], non-Hispanic White [81.5%], urban-residing [80.3%], and cash-pay at intake [74.0%]), 2782 (83.3%) completed a UDS within 30 days (90.0% among protocol-adherent patients, 67.0% among protocol-nonadherent patients). A total of 2750 of 2817 (97.6%) patients retained more than 90 days completed 1 or more UDS, as did 2307 of 2314 (99.7%) patients retained more than 180 days. Younger patients, patients of a racial and ethnic minority group, those living in urban areas, and cash-pay patients were less likely to complete a UDS in the first 30 days. Buprenorphine positivity increased (from 96.9% to 98.4%, P = .004) and opioid positivity declined (from 7.9% to 3.3%, P < .001) over time.

Conclusion &

Discussion: We found that most patients completed a UDS in the first 30 days of care, and an overwhelming majority completed one within the first 90 days of care, suggesting that drug testing was mostly feasible to conduct over an exclusively telehealth treatment platform without requiring any in-person visits. We also found low rates of opioid use across all time points in care, with additional declines from early to later points in care, which suggests that buprenorphine delivered in TBOT settings is an effective treatment for OUD, and is consistent with favorable retention outcomes observed in this and other TBOT settings. To our knowledge, this is the first study characterizing UDS administration and results in an exclusively TBOT setting, an important step toward identifying the appropriate role and optimal processes for UDS in remote care settings.
A key limitation of this study is that patients in TBOT settings and those in our sample in particular may not be representative of all patients with OUD. Indeed, the rate of opioid positivity in our sample was substantially lower than that observed in in-person OBOT settings, which raises questions about how these populations may differ.

References:
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