Post-its from Practice:
Taking the piss: How often do we need to do it? (Oct 2009)
After years of yo-yoing between heroin and crack use, and regular stints in prison, Sinead had stabilised well on 90mg of methadone after almost a year in treatment with us. Her ultimate aim was to become drug-free but she realised that she couldn't achieve that in London. So, after much thought, she decided to return home to Ireland.
I knew the system wasn't perfect in Ireland but I believed that she would be able to get methadone. What I hadn't banked on was their "taking the piss". I spoke to a helpful drug worker at the nearest service who asked me to fax a referral, which I did. Very shortly afterwards he phoned back and asked for copies of the urine tests. I explained that the results of the last two (one the week before in preparation for moving and one two months before) were enclosed in the letter, and that they were positive for methadone and cocaine. He sounded confused and enquired where the rest were.
I then discovered that in Ireland, it is recommended that patients on methadone treatment have a test at least once a week .The cost of a single urinalysis test for drugs of abuse is around 11 Euro! With over 10,000 patients registered on the Central Methadone Treatment List the annual bill is around 5,500,000 Euro, which doesn't include costs such as staff time and other related activities.
Saying that, I had been equally shocked only six months before by a GP at a training session who stated that he kept everyone on supervision forever and never did urine tests. His rationale had been that he didn't care what his patients took but he wanted to ensure that what he prescribed ended down the right throat. Surely neither extremes are right?
I was surprised that I had thought to do a further test on Sinead before transfer as our usual policy follows the DoH's Drug Misuse Guidelines on Clinical Management 2007 which states that the testing of patients who are established in treatment can be done much less frequently. It states for example, that "random urine checks may be helpful ...at least twice a year".
Around the world there are varying policies. The Australians, for example, state that there is no research evidence to indicate that urinalysis can reduce illicit drug use but continue to take and, in the US, although regulations vary from state to state, best practice guidelines recommend a minimum of eight drug tests per year.
So who is right? Why are we doing piss tests? The use of urines seems to have very little supportive evidence. The theory is that people with opiate negative tests are less likely to divert their prescribed methadone, and that this can be reliably used to determine who gets unsupervised doses of medication. However, I can find no evidence backing up this theory.
Perhaps at the beginning of treatment it is helpful both for confirmation of drug use, for medico-legal reasons and to confirm compliance. Occasionally I have patients who request them to support their own change and motivation, which seems fine in that it supports the patient. My experience is that people are very honest about their drug use and research shows almost complete concordance if there are no punitive responses to the test results.
Another worrying thought is that I know I have had more than one row with the odd social worker who is obsessed with illicit drug-free urines and who will try to use them to determine if a parent is suitable to care for their children rather than basing this decision on their competence, assessment of their home or even their alcohol use.
So, while I am on this little rant, I can't finish before challenging the terminology the field uses: "dirty" and "clean". I feel using terminology like this immediately sets up a tension between the patient and the worker.
We have just updated our urine policy at Lonsdale and it seems to get more liberal but all things considered, perhaps we should reduce it to: 1) will this test benefit the patient or their treatment or 2) will this test protect or help the prescriber? If the answer to both is no, perhaps we should stop doing them?
Thanks to Dr Cathal Ó Súilliobháin, a GP working in addiction and for a wonderful fuller analysis of this topic see www.imt.ie.