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Testing's role in buprenorphine treatment programs

May 1, 2010
by Michael Casarico and Jodie Casarico
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Since its introduction in 2002, buprenorphine has proven to be a powerful tool in the treatment of opiate addictions. Buprenorphine curbs the craving for opiates, and can send addictive behaviors into remission. Because of the medication's success, outpatient treatment programs that utilize buprenorphine have been opening at a rapid rate. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the nation currently has more than 11,000 physicians qualified to dispense buprenorphine, and more than 1,800 buprenorphine treatment locations.

Drug testing is an essential part of the buprenorphine treatment process for a variety of reasons. Most obviously, it is a valuable tool for physicians and clinicians as they gauge program compliance. It demonstrates that the client is taking the medication as prescribed, while refraining from “supplementing” with other drugs or alcohol. This information can be used to benefit both the client and the treatment center: Drug testing can identify a client's need for additional support, while protecting the center's exposure to liability risk through awareness of a patient's possible prescription misuse.

Equally important, drug testing supports the patient's ongoing abstinence. In our former practices as drug and alcohol treatment professionals, we witnessed that clients who receive random drug testing are held accountable for their actions, and thus have more incentive to refrain from substance use. In fact, the observations made in our respective practices motivated us to develop the drug testing protocols currently found in our Vermont-based company, Burlington Laboratories. Clinician Charles Scott Earisman, MA, LCMHC, LADC, notes, “I think that carefully negotiated agreement to use drug testing as part of therapy helps the client feel that their ambivalence is acceptable and understood, and helps the therapist develop a trust in the client. Testing, ultimately, is a tool in developing the therapeutic relationship.”

Vital elements

Detailed drug testing can be critical in determining the “big picture” for a client in treatment, offering information about use of other drugs or alcohol. For example, without a specific test for oxycodone, its use may go undetected, as lower doses of oxycodone will not trigger a general opiate positive.

Alcohol metabolite (EtG) testing also has proven to be a critical tool for buprenorphine treatment centers. Where a standard alcohol (ETOH) screen tests only for alcohol currently in the client's system, the EtG test is an indicator that is able to detect alcohol use up to three days post-consumption. In buprenorphine treatment, alcohol testing is vital. Buprenorphine is highly contraindicated with alcohol; the combination can be dangerous. If alcohol use goes undetected, the client is placing himself and the community at risk.

Additionally, studies show that alcohol use during any treatment program can dramatically reduce success rates. From our experience running outpatient programs, we know that invariably there are clients who truly believe that they are able to limit their addiction successfully. They may think, “I'm a heroin addict. I don't have a problem with alcohol.” But in our experience, patients who maintain this attitude never completely give themselves over to the abstinence model. They will experiment with “controlled using.” This behavior more often than not ends up with the client relapsing back into old using behaviors.

Unfortunately, EtG testing still is seen by many to be prohibitively expensive and impractical as a treatment tool, therefore making access to the testing limited. Because alcohol is available legally in so many outlets, we believe people in recovery can only benefit from EtG monitoring. We believe it so strongly that our company includes free EtG results with any other tests.

Synergy Counseling Group, an outpatient drug treatment center focused on the use of buprenorphine, considers drug testing to be one of the most valuable tools it has at its disposal for tracking the compliance of its clients. Synergy CEO James Hamel, LADC, CADC, ICADC, explains, “Alcohol use was difficult to track prior to our EtG test, and we could only catch them sporadically with an alco-sensor test.” He goes on to say, “When we enhanced the drug testing we do, and added an EtG test at no cost, we discovered that there were a significant number of clients drinking while in the program. It became a major treatment issue for us that we were previously unaware of. We were able to take immediate action to address the situation.”

Confirmation testing provides further information for the physician or clinician in the treatment setting, as it can indicate potential prescription misuse and/or buprenorphine diversion. The standard initial screening tests for buprenorphine will show only the undigested buprenorphine that is passed through into the urine. Confirmation testing will show the total buprenorphine un-metabolized and metabolized buprenorphine (nor-buprenorphine). If a client is tampering with the urine by spiking it with buprenorphine powder, it will test positive on the screening test but not on the confirmation test because nor-buprenorphine would not be present. If the client is compliant and taking buprenorphine as directed, the ratio between metabolized and un-metabolized buprenorphine will remain stable. The ratio will drop if the client skips one or more doses.