Taking the piss: is HSE drug testing wasting millions?

Dr Cathal Ó Súilliobháin — a GP working in addiction counselling — writes that the current policy of weekly testing is costly and not evidence-based

The cost of a urinalysis test for drugs of abuse is around €11. In Ireland, it is recommended that patients on methadone treatment have a test at least once weekly.
There are around 10,000 patients registered on the Central Methadone Treatment List. The annual bill comes to around €5,500,000.
There are other costs associated with this activity. Extra male and female staff are needed in clinics to supervise urine-sample collection. The cost of these grades of staff are a significant part of the wage budget of the Addiction Service.
In most other countries providing similar drug-treatment programmes, testing of patients who are established in treatment is done much less frequently.
The British Department of Health ‘Drug Misuse Guidelines on Clinical Management’, for example, recommend ‘random urine checks may be helpful e.g. at least twice a year’.
No research evidence
The Australian National Expert Advisory Committee on Illicit Drugs Clinical Guidelines for methadone maintenance states that there is no research evidence to indicate that urinalysis can reduce illicit drug use. Medicare allows for a maximum of 21 urinalysis tests per patient per year, but it is expected that the average number of tests will be significantly lower and will decrease the longer a patient is in treatment.
In the USA, although regulations vary from state to state, the Substance Abuse and Mental Health Service Administration (SAMHSA) best practice guidelines for methadone maintenance recommend a minimum of eight drug tests per year.
The rationale for testing more frequently in Ireland is historical and based on a philosophy of treatment that is not supported by any medical research evidence and which, in general, is not now accepted by most doctors actually treating drug users.
Ninety-five per cent of registered opiate users in Ireland are treated by GPs either in their practices or in HSE clinics.
Level 1 and 2 GPs operating under the Methadone Protocol Treatment scheme are obliged by their contract to follow the ICGP guidelines ‘Working with Opiate Users in Community-Based Primary Care’, which recommend a urine screen at each weekly visit.
Although testing for drugs of abuse seems a simple and straightforward activity, there are many misconceptions around the significance of results held by both medical personnel and others in the legal and social services.
‘Take-away’ doses
It is assumed, for example, that those with negative opiate tests are less lightly to divert their prescribed methadone, and this is used to determine who gets ‘take-away’ (unsupervised) doses of medication.
There is no evidence for this assumption. In fact, anecdotally, it appears to be the more ‘stable’ patients who produce opiate-negative urine samples and attend their pharmacist only once weekly who tend to reduce their medication and sell the surplus to addicts who do not or cannot enter treatment.
Results of urinalysis are often a major influence on decisions to determine if a drug-using parent is suitable to care for their children. It is natural that people making these difficult decisions look for something objective on which to make their judgments.
A recent presentation by Dr Garrett McGovern to a symposium on child-care issues in Dún Laoghaire, however, presented evidence indicating that testing for drugs of abuse does not provide useful information in making these types of decisions.
Extensive assessment
Unfortunately that type of decision can only by made after extensive face-to-face assessment of parents and their children and comprehensive assessment of the home and family situations. For overstretched childcare services, this is often difficult and even with this level of assessment, one is still guessing as to the level of risk.
I have borrowed the title for this piece from a presentation at an ICGP/Eastern Health Board conference on drug treatment by John O Reilly, who worked as a general assistant in the early Addiction Service Clinics in Dublin.
John, an accomplished musician, sadly passed away this year. He was a kind and thoughtful man who treated patients with compassion and understanding. He also had a lively sense of humour.
A significant part of his duties was taking supervised urine samples from patients in addiction clinics and his presentation centred on the various ingenious methods patients used to circumvent the system of monitoring their drug use by urinalysis.
In those exciting days of unlimited budgets for the fledgling drug treatment services (the early boom years), patients were routinely screened by urinalysis twice weekly. No one gave a thought to cost (or perhaps more importantly, relevance to treatment outcomes) of urinalysis.
Those showing positive results for illicit drugs either had their dose of methadone reduced (in the mistaken belief that it was safer) or even had their treatment terminated for a period of time. I do not now remember the rationale behind that one but it was I believe, equally unsupported by any sort of research evidence.
Highly entertaining
John’s presentation was highly entertaining with tales (and even photos) of all sorts of devices, tubes, bladders and fake body-parts used by the enterprising drug-takers to beat the system.
Relatively new to the drug treatment world, I was struck by the difference in the relationship between the patients and the treatment service and the staff, including doctors, who were treating them.
Twice-weekly supervised collection of urine samples seemed to me, at the very least, an undignified process, both for the patient and the person supervising the sample collection.
Even the language used around urinalysis was different. Positive opiate tests were called ‘dirty’, negative were ‘clean’. One can still hear doctors working in the addiction service today, referring to a patient, say, ‘he’s dirty this week’. Raised a strict Freudian, I found this very strange (but very interesting).
Compared to patients in general practice, where I had worked for the previous twenty years, drug users were seen and treated as a completely different category of customer.
They were considered to be inherently untrustworthy, and incapable of telling the truth about their drug use.
If one did not explore the dynamic of the doctor/patient relationship, this appeared to be true. Patients prescribed methadone would frequently deny heroin use when their urinalysis would be positive for opiates.
When patients were assessed for treatment, however, they would be very open and frank about their drug use.
It became clear to me, once I started to explore the literature from other countries, that the reason for this change in their behaviour on entering treatment was a difference in the goals of treatment of the doctor and the patient.
Total abstinence
Doctors, at that time, generally believed that patients should achieve total abstinence from illicit drugs shortly after starting methadone treatment. If they did not achieve this goal, they were considered to be lacking in motivation, and negative contingency methods were employed to remedy this.
There is strong research evidence to show that this approach is ineffective, and can in fact be counterproductive, causing patients to leave treatment.
There is also strong evidence that patients outside treatment are much more at risk of death as a consequence of their drug use.
Drug users, on the other hand, enter treatment for a variety of reasons. Most seek relief from the problems (legal, social, relationship, etc) related to sourcing the opiate they need to function every day.
Achieving abstinence from illicit drugs may not be a high priority for them. Similar to tobacco addicts, many opiate addicts express a desire for total abstinence, but few seem to achieve it at any given time.
Tobacco and Heroin
Interestingly, the statistics on tobacco and heroin addiction are strikingly similar in this respect. If asked, 70-80 per cent of both groups will state that they wish to discontinue their drug. The percentage succeeding in achieving abstinence at each attempt, sadly, is measured in single figures.
Relapse of these small numbers in both groups is similarly high in the following year.
Relapse to opiate use after detox is associated with increased mortality.
This does not mean, of course, that we should not try to encourage and support patients to achieve abstinence from whatever substance is causing them problems.
It does suggest, however, that doctors must have more realistic expectations of the outcomes of treatment.
Most doctors working in the treatment of drug users in Ireland now accept these realities and practise from a harm-minimisation perspective.
This means that the goal of treatment is to achieve the greatest level of reduction of harm from drug use possible for each individual at any given time.
Such an approach spans the spectrum of interventions — from instruction in safer injecting techniques and ‘needle exchange’ programmes to methadone maintenance programmes to achieving abstinence through slow reduction or detoxification programmes.
For the majority of patients in a treatment programme, the best possible outcome at a given time will be achieved by a methadone maintenance programme.
Punitive measures
With increased experience in drug treatment in Ireland and exposure to the extensive international evidence base around drug treatment, most doctors now agree that punitive measures such as dose reductions and exclusion from treatment are ineffective, and associated with poor treatment outcomes.
The change in approach has also altered the way patients relate to their doctors. When there is no negative consequence for the patient to reporting drug use (the response will often now be to increase dose of methadone), patients do not feel the need to lie to their doctors about their drug use to get effective treatment.
This also reduces pointless confrontations with patients, which in the past have often led to violent incidents.
All best practice guidelines (including those quoted above) stress that urinalysis should not be used as a substitute for proper assessment of the patient. As we were always told in medical school, ‘treat the patient, not the test result’.
There is a need for doctors treating drug users to be able to test their patients for drugs of abuse. This is especially true at initiation of treatment and on a random basis during long-term treatment programmes.
However, there is no evidence that the level of testing carried out in Ireland is justified.
There are also other effective methods of testing, such as oral fluid testing, which require much less staff, give instant results and is a much more dignified process for the patient.
The enormous cost of the present levels of urinalysis for drugs of abuse could perhaps be ignored when the HSE seemed to be operating on unlimited budgets, but times have changed, as we are all painfully aware.
Review of guidelines
Faced as we are with proposed cutbacks in frontline services, and when adequate drug treatment services are not available in most areas outside greater Dublin (but heroin is), it is time for an objective review of guidelines which compel doctors treating drug users to waste the limited resources given to this essential area of practice.