4 April 2002

Urine testing in treatment - how often?

Fellous J, Lowenstein W, Gourarier L, Bonan B, et al. Relevance of urinalysis monitoring of methadone maintenance patients: a clinical-biological agreement on 41 patients. Addiction Biology (2000) 5:313-318

This interesting report from a Paris addiction treatment service tells us much about good medical treatment with methadone as well as showing the benefits and limitations of urine drug testing in the clinical environment. These researchers reiterate that urine testing should never be used punitively but more as a clinical guide or reminder. They state that such testing is 'still used by some as a disciplinary measure despite recommendations of clinicians and epidemiologists'. 'It should not be performed as a repressive imposition which will probably lead drug abusers to falsify their urine samples' (6 references given).

The study's sub-group of the clinic population comprised 41 long term methadone maintenance treatment (MMT) patients with mean age 33, 57% male, 92% injectors. Dose ranges were also typical with 90% receiving between 30 and 120mg daily (mean dose 72mg). 5% were prescribed in excess of 120mg. The overall clinic's annual retention rate appeared to be a staggering 96%.

All patients had at least one test every 2 months during the 12 months of the trial which examined results in comparison with clinical history given to health professionals. The simplified addiction severity measure used self-report of drug use and medical/social consequences. There was a 'very poor agreement' with urine test results. The authors conclude that urine test results should be used as a surveillance to alert the physician to early relapse and to schedule earlier consultations for action to be taken such as dose adjustment, counselling, etc.

This report underlines that urine testing has still not been proven to have any effect on the outcomes of treatment or prevention, despite popular belief of a therapeutic benefit from such surveillance. Urine testing, as long as it is (1) supervised (witnessed and/or temperature tested) and (2) tested by reliable and sensitive methods and (3) used without any threats of adverse consequences on treatment - is an accurate way of determining a subject's recent intake of drugs. This provides evidence for research into medical, legal or epidemiological aspects of psychoactive drug use. It probably also has a place in improving clinical outcomes but this remains to be proven by comparative research.

I was intrigued to learn this week that the Australian Health Insurance Commission has increased from 21 to 36 the maximum rebateable number of urine toxicology tests per annum. Why ever would they fund additional tests per year when there is no evidence that they are of any benefit? Could politics have influenced matters?

comments by Andrew Byrne ..

further references:

Chutuape MA, Silverman K, Stitzer ML. Effects of urine testing frequency on outcome in a methadone take-home contingency program. D&A Dependence 62 (2001) 69-76

Chermack ST, Roll J, Reilly M, Davis L, Kilaru U, Grabowski J. Comparison of patient self-report and urinalysis results obtained under naturalistic methadone maintenance conditions. D&A Dependence (2000) 59:43-49

Ditton J, Cooper GAA, Scott KS et al. Hair testing for 'ecstasy' (MDMA) in volunteer Scottish drug users. Addiction Biology (2000) 5:207-213