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There's certainly a lot to digest from yesterday's Q2 Alberta Opioid Response Surveillance Report. https://www.alberta.ca/opioid-reports.aspx
The numbers, to put it plainly, are devastating.
Long and educational thread to follow on one aspect of the report that I struggle to understand.
The numbers, to put it plainly, are devastating.
Long and educational thread to follow on one aspect of the report that I struggle to understand.
On page 4, there is a section titled "AHS Opioid Dependency Program - An example of impacts during pandemic peak". It shares the following data:
It appears to be looking at the percentage of urine drug tests performed at the ODP programs that are positive for either methadone or buprenorphine. For those less familiar with OAT treatment, these are the 2 most commonly used oral medications to treat an opioid use disorder.
Urine drug screens are done at variable intervals throughout a person's treatment to monitor for ongoing drug use, especially for drugs that would be dangerous to combine with treatment medications such as alcohol or other sedatives.
They can also be helpful for patients to understand what they are using. I still have a number of patients who tell me they are using "heroin". To have a urine result showing the presence of fentanyl and carfentanil can be an important piece of knowledge and harm reduction.
(Truthfully though, urine drug screens are mostly just part of the outdated and paternalistic system of care we have set up around prescribing OAT medications but I digress....)
So back to the report. What we see is a high number of urine drug tests done from the ODP programs in 2018 and 2019 that are positive for methadone or buprenorphine. Makes sense. Patients who are prescribed medications will test positive for those medications.
From March to April 2020, we see a steep decline in the percentage of tests positive for methadone or buprenorphine, and this is where the report loses me, as an indicator of loss of treatment adherence. This last bit is what doesn't make any kind of sense. Let me explain.
Let's start by looking at why a urine test for a patient in an OAT program might be negative for methadone or buprenorphine. There are 2 extremely likely answers:
1. The patient is prescribed SROM (this is a 24h morphine medication also used to treat opioid use disorder).
1. The patient is prescribed SROM (this is a 24h morphine medication also used to treat opioid use disorder).
These patients are not prescribed methadone or buprenorphine, just morphine, so no positive tests ever.
2. Patients are often asked to do a urine sample prior to starting any treatment. You're not going to test positive for a medication that you haven't started yet.
2. Patients are often asked to do a urine sample prior to starting any treatment. You're not going to test positive for a medication that you haven't started yet.
What if a patient stops taking their medication, won't they also test negative? Well sure. But when a patient stops treatment, they stop ALL aspects of that treatment. In my 12+ yrs practice, I have never had a patient stop their medication but still present for drug testing.
And even if a patient is not taking their medication regularly, they are generally still consuming at least one dose every 1-2 weeks witnessed by a pharmacist. These patients will continue to test positive.
In the EXTREMELY RARE case where a pt provides a urine test that is expected to be +ve for methadone or buprenorphine but isn't, it might be:
1- They have stopped dosing, found a way to circumvent the witnessed dosing requirement, but still want the Rx (I've NEVER seen this!!).
1- They have stopped dosing, found a way to circumvent the witnessed dosing requirement, but still want the Rx (I've NEVER seen this!!).
2- The urine sample is not their own (I've only VERY rarely seen this and it is only because of the outdated and paternalistic system of care we've set up around prescribing OAT medications, I digress....)
So why the drop of in March/April 2020 on percentage of urine tests positive for methadone or buprenorphine? Because most OAT providers, and I'm assuming AHS ODP was the same, stopped the bulk of urine testing they were previously doing.
No one was asking patients already on treatment to come in for the sole purpose of a urine test (the least important part of someone's treatment in my opinion). We were encouraging them to stay home and isolate as best able.
I'm guessing that most of the urine tests being done in this period were for new patients, those walking in for assessment to urgently start on treatment. So a greater percentage of these were likely pre-treatment urine tests expected to be -ve for methadone or buprenorphine.
So the report says this:
...but doesn't provide any data to support the conclusion that a large number of patients stopped treatment during this period. A better measure would have been to look at prescriptions filled and appointments attended - both far more accurate indicators of treatment adherence.
If someone familiar with it would like to correct me - to clarify if patients on SROM and patients not yet started on any treatment were excluded from the data set - I would be very interested in hearing that and any other interpretation of this data or why it was included.
Summary:
1- ODP clinics prescribe 3 types of medications, not just methadone and buprenorphine.
2- Pts do urine tests prior to starting treatment as well.
3- When pts stop treatment, they stop urine drug testing.
4-To me, this data does not show a drop off in treatment adherence.
1- ODP clinics prescribe 3 types of medications, not just methadone and buprenorphine.
2- Pts do urine tests prior to starting treatment as well.
3- When pts stop treatment, they stop urine drug testing.
4-To me, this data does not show a drop off in treatment adherence.
