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Commentary: Pausing Drug Testing During the Pandemic Is Not the Answer

Recommendations to halt drug monitoring has come at precisely the same time when multiple data sets show a dangerous rise in drug misuse and overdose-related deaths. We need a better plan.

Mistakes are not a problem – not learning from them is. A commentary.

 

Addiction Medicine is one of the more rapidly growing medical specialties in the US. The American Society of Addiction Medicine (ASAM) is at the forefront of advocacy, policy, and education in support of physicians and other healthcare professionals who treat patients with substance use disorders (SUD). One of the basic tenets of treatment, when dealing with SUD patients, is that they undergo random – yet frequent – drug testing. Testing protocols typically involve interaction with healthcare personnel.

As a result of the novel coronavirus pandemic, there is obvious concern about the associated risk of acquiring infection by both patients and healthcare personnel. In June 2020, ASAM issued guidance on adjusting drug monitoring protocols during the COVID pandemic; these guidelines were updated in September 2020.

The guidelines highlight several circumstances where the benefit of drug testing outweighs the risk of COVID-19 exposure. However, the core recommendations propose pausing, limiting, or exploring “options for drug testing at a distance” in the face of the pandemic.

Specifically, ASAM suggests that clinicians consider other ways of obtaining information about medication adherence to supplement or inform medication management and other treatment decisions in order to reduce reliance on drug testing. In its most recent update, ASAM stresses (bolded in the ASAM document): “Drug testing for routine purposes is not recommended at this point”.

A discontinuation of regular drug monitoring comes at a time when multiple data sets are pointing to a dangerous rise in drug misuse and overdose-related deaths. (Image: iStock)

These recommendations come at a time when multiple data sets point to a dangerous rise in drug misuse and overdose-related deaths. The American Medical Association (AMA) publishes Issue Brief reports on topics of interest regarding public health – their September 8, 2020 brief noted that more than 40 states have reported increases in opioid-related mortality. The AMA stated that it was “greatly concerned” by the increasing number of reports from national, state, and local media suggesting increases in opioid-related mortality – particularly from illicitly manufactured fentanyl and fentanyl analogs.

Reports collected in real time by the Washington, DC, based Overdose Detection Mapping Application Program group (ODMAP) also found a significant spike in the number of overdoses nationally. A July 1, 2020 Washington Post article noted that compared to the same months in 2019, overdoses jumped 18% in March, 29% in April, and 42% in May.

In addition to overdose surveillance systems, national laboratory data has pointed toward an increase in drug misuse since the start of the pandemic. A PAINWeek 2020 poster presentation noted that tracking national laboratory data can yield early signals to our country’s reemerging drug abuse problem. The data, sourced from and supported by Quest Diagnostics, suggested that not only has drug testing decreased dramatically since the start of the pandemic but nonprescribed use/positivity of fentanyl, one of the drugs most responsible for the overdose epidemic, increased by 35% compared to the weeks before the COVID-19 pandemic and lock-down. In addition, dangerous combinations of non-prescribed fentanyl with other drugs such as amphetamines, benzodiazepines, other opioids and cocaine were also noted.

In a similar study, Millennium Health conducted an analysis of more than 500,000 definitive urine drug test (UDT) results and noted significant increases in positivity for non-prescribed fentanyl, cocaine, heroin, and methamphetamine in the periods after COVID-19 was declared a national emergency.

The CDC’s Morbidity and Mortality Weekly Report from June 24-30, 2020 focused on mental health, substance use, and suicidal ideation during the pandemic. They reported that during June 2020, 40% of US adults reported struggling with mental health or substance use. To reduce potential harms of increased substance use related to COVID-19, they recommended that resources including social support, comprehensive treatment options, and harm reduction services remain freely accessible.

The National Institute on Drug Abuse (NIDA) recognizes that the COVID-19 pandemic presents unique challenges for people with substance use disorders. A collaborative report published September 4, 2020 was titled “Why Testing is the Key to Getting Back to Normal.” This document was referring to COVID-19 testing –not drug testing. It is these authors’ opinion, however, that it is time to return to widespread use of the only objective tool in our toolbox to determine if a person is misusing drugs (or alcohol): DRUG TESTING.

As noted, ASAM has been a leader in education and advocacy surrounding drug monitoring. They published the “Appropriate Use of Drug Testing in Clinical Addiction Medicine” (J Addiction Medicine, May/June 2017) to provide guidance about the effective use of drug testing in the identification, diagnosis, treatment, and promotion of recovery for patients with, or at risk for, addiction. They concluded that although drug test results should be not be used as the sole determinant when making patient care decisions, drug testing should be a routine part of initial and ongoing patient assessment of recent substance use in all addiction treatment settings. Drug monitoring results should be used in conjunction with patients’ substance use self-reports, treatment history, psychosocial assessment, and physical examination.

We respectfully propose that clinicians, regulators, and medical societies – including ASAM – acknowledge the increased risk factors for drug and alcohol misuse during times of crisis. We must recognize the rapid reversal of drug misuse trends since the start of the COVID-19 pandemic and relate its potential relationship to the pause in clinical drug testing. There are numerous ways to secure a drug matrix sample including point-of-care tests, clinician office obtained samples, home-testing devices observed via telemedicine and sent to the lab, or recommendations for use of a laboratory’s patient service center. Untreated, SUDS can be harmful and even fatal while early intervention, when relapse occurs, is typically associated with improved outcomes.

It is, therefore, our opinion that routine – and safe – drug monitoring needs to be resumed to maintain long-term goals. Given the troubling increases in substance misuse seen during this pandemic, resumption of drug testing is a necessary tool in the battle to reverse this unhealthy trend. 

 

 

Disclosure: Dr. Gudin is a Medical Advisor to Quest Diagnostics. He participated in an educational video series on how, why, and when to test patients for a PPM clinician guide. 

 

Last updated on: November 2, 2020
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