A commentary on “Urine testing in methadone maintenance treatment: applications and limitations”

Abstract

Urine surveillance is an important tool for methadone treatment programs that is typically used to determine whether clients are receiving the proper dosage of methadone and whether they are using any illicit drugs. Results from urinalysis are used to monitor treatment compliance and progress. Many treatment staff see urinalysis as a therapeutic tool that can be used to support the addiction recovery process. Results can be used to help confront unhealthy behaviors, break through denial, and to support clinical progress such that persons receiving treatment are enabled to abstain from heroin and other drug use. In ‘‘Urinalysis as a Clinical Tool’’, Ira Marion (1993) distinguishes urine ‘‘screening’’ from urine ‘‘testing’’ and asserts that screening is more typically the practice employed by methadone treatment programs. Testing is the more rigorous of the two, more expensive, and frequently involves followup tests where test results clarify clinical issues such as diversion or other drug use. Screening is a more limited procedure, but according to Marion, ‘‘in the context of regular, routine, and random surveillance, can yield a patient profile to be used in treatment planning, counseling, casework, and determining the adequacy of the patient’s methadone dosage, particularly as patterns emerge during treatment’’. When considering the applications and limitations of urine surveillance the distinction between testing and screening takes on major significance. There are organizational and resource problems that compromise the potential effectiveness of urine testing within methadone maintenance programs. It is typically the case that methadone treatment staff have caseloads that exceed desired levels, making it difficult to conduct urine surveillance strategies with the frequency and rigor necessary to produce reliable, conclusive data. Treatment staff, then, are likely to be restricted in their ability to do much more than to implement screening at the minimal level required by regulatory agencies. The combination of limited fiscal resources and large caseloads creates an environment where it is difficult to meet even minimum requirements. (In New York State, those minimal requirements involve weekly screenings for the first three months of treatment and once monthly thereafter, unless assessment indicates a need for more frequent screening.) Given the likelihood that a program is screening once a week or less and using a less costly, less sophisticated screen, it may be assumed that urine screens are yielding limited data related to dosage and drug use. However, the screens can provide a valuable snapshot of a client’s performance at a given moment in the treatment process that, along with other clinical data, can be used to help assess that client’s clinical progress. Frequent random urine testing, the use of confirmatory testing, and testing methods that promote the integrity of test results would increase the reliability and thereby the utility of the results as an indicator of treatment compliance and effectiveness. However, given the workforce and resource limitations that impact methadone treatment programs, it is likely that programs will continue to rely on less frequent, less reliable screening protocols. Advocacy is clearly needed for additional resources to enhance the likelihood that testing and screening can be conducted as clinically needed. Even with the serious workforce and resource challenges confronting methadone treatment programs, they can, nonetheless: