Urine drug testing (UDT) at indicated intervals is the standard of care in OAT programs and can be used to assess adherence to treatment, validate self-reported use of opioids or other substances, detect use of other substances which may affect safety (e.g., benzodiazepines), and evaluate treatment response and outcomes (e.g., abstinence from heroin or other opioids). However, the extent of the utility and effectiveness of UDT is unclear. A 2019 critical review of the literature supporting the use of UDT as a standard of care for individuals on OAT found insufficient evidence to determine UDT’s effectiveness for both patient and community health outcomes491 and called for more research to determine the relationship between UDT frequency and health outcomes.491 This finding accords with a 2014 systematic review, which found insufficient evidence to demonstrate the utility of carrying out UDT for medical management of individuals receiving opioids.492 This review looked at the use of UDT for both opioid analgesia and OAT. While the overall findings were insufficient to demonstrate the utility of UDT, weak evidence was found for the use of UDT in OAT.
All UDT should be accompanied by a discussion with the patient about their substance use and care plan and should be based on the principles of improved patient care and outcomes. The frequency of UDT should be determined by therapeutic need, with an understanding that more frequent testing has not been shown to decrease substance use.493 However, a general principle of more frequent testing at the beginning may be followed.
Clinicians should use UDT when test results may impact clinical management for a given patient; however, UDT results should not be the only factor considered in clinical decisions. Urine drug testing should be used along with collateral information, self-report, and clinical assessment for the monitoring of treatment.493 A pattern of tests positive for the prescribed medication and negative for unexpected substances suggests a treatment plan is effective, whereas the opposite indicates the need for treatment plan adjustments.493 These may include discontinuation of take-home doses, increased psychosocial interventions and support, a higher level of care, increased patient education, a dose increase, more frequent UDT schedule, or trialing a different medication option.493
In the absence of clearer evidence supporting the use of UDT for individuals receiving prescribed opioids, UDT should be used for specific purposes, such as:
- Confirming unregulated opioid use during baseline assessment
- Supporting decision-making regarding take-home doses
- Confirming that the medication is being taken
- Screening for ongoing non-prescribed or unregulated opioid use, which may indicate the patient is undertreated or needs additional support
- Detecting the presence of other substances, including substances the patient may be unaware they have ingested
- Evaluating treatment response and outcomes
Information about drug testing and patient-provider expectations should be discussed with the patient when initiating OAT.493 In particular, clinicians should emphasize—and ensure that patients understand—that UDT is performed for all patients prescribed OAT and that the results will not be used punitively or as sole grounds to discontinue treatment, but may be used to inform changes to their clinical management.
This appendix provides broad guidance on using UDT for OUD care, including suggested frequency, information on point-of-care and laboratory UDT, and information on using UDT in patient prescribed slow-release oral morphine. More detailed guidance, including general practices, ordering UDT, interpreting results, and managing unexpected results, is available in Urine Drug Testing in Patients Prescribed Opioid Agonist Treatment—Breakout Resource. In any instances of incongruent guidance between this guideline and the Breakout Resource, the guidance contained in this guideline supersedes the guidance in the Breakout Resource.
A5.1 Frequency
Determining the frequency of UDT should be at the discretion of the prescribing clinician. Urine drug testing frequency should be guided by therapeutic need, with an understanding that there is insufficient evidence to suggest that more frequent testing affects substance use.493 A general principle of more frequent testing at the beginning of treatment may be followed. Generally, UDT should be performed at baseline and when patients display a change in clinical status.493 During initiation and dose escalation, urine drug testing should be performed monthly or more or less frequently as required when clinically indicated and at the discretion of the clinician to confirm self-reported abstinence from unregulated opioid use and/or when treatment plan changes to include take-home dosing and when UDT results would change clinical management. More frequent urine drug tests are not necessarily required if ongoing substance use is fully disclosed by the patient.
Following initiation, and once a patient has stabilized on a given dose of OAT, UDT should be performed when the results would change clinical management. Patients who miss UDT appointments should be reassessed as this may indicate risk of return to unregulated opioid use or diversion.
Table 29. Suggested Urine Drug Testing Frequency
| Treatment stage | UDT schedule |
| Initial confirmatory testing | Performed to confirm unregulated opioid use prior to initiating OAT |
| Buprenorphine/Naloxone | |
| Induction and stabilization | Monthly or more or less frequently as required and when clinically indicated |
| Maintenance | When clinically indicated |
| Take-home doses |
2–4 tests per year or when there are any safety concerns Frequency of UDT is as required when clinically indicated |
| Methadone and slow-release oral morphine | |
| Initiation, titration, and stabilization | Monthly or more or less frequently as required and when clinically indicated. In circumstances where UDT is occurring less than monthly, patient safety can be increased with daily witnessed ingestion. |
| Maintenance | When clinically indicated |
| Take-home doses |
6–8 tests per year or when there are any safety concerns Frequency of UDT is as required when clinically indicated |
A5.2 Immunoassay-based UDT
Point-of-care urine immunoassay-based drug testing is useful for providing immediate feedback to patients, supporting real-time discussions and shared decision-making (e.g., prescribing take-home doses). Physicians are compensated through MSP (fee code P15039) for performing and interpreting point-of-care UDT as part of opioid agonist treatment up to a maximum of 26 UDT per patient per year; however, UDT should only be performed for a specific purpose and according to therapeutic need. For that reason, many patients will require far fewer than 26 UDT per year.
If point-of-care immunoassay-based UDT is unavailable or infeasible because of low patient volume or cost considerations, patients can be referred or urine samples collected in clinic can be sent to a local laboratory service for immunoassay-based UDT.
Point-of-care UDT are typically available for the following substances:
- Opiates (unspecified)
- Oxycodone
- Buprenorphine
- Methadone metabolite (EDDP)
- Fentanyl
- Hydromorphone
- Benzodiazepines (unspecified)
- Amphetamines (unspecified)
- Cocaine metabolite
- Cannabinoids
- Alcohol
It is important to note that the immunoassay opiate test strip panel is designed to detect morphine or substances in which morphine is a metabolite, including heroin and codeine. The immunoassay opiate test strip cannot reliably detect synthetic and semi-synthetic opioids such as methadone or fentanyl. Individual tests for semi-synthetic and synthetic opioids are available but must be ordered separately.
Vendors typically offer a standard panel that includes tests for several substances. Clinicians should review what is included in standard panels prior to ordering and request additional single-agent test strips if a substance of interest is not included in the panel (e.g., buprenorphine, fentanyl). Given the wide-spread contamination of the street drug supply in British Columbia, point-of-care tests should include fentanyl.
Availability and accuracy of tests vary by product and manufacturer. Clinicians should carefully review the manufacturer’s product insert to determine which drugs within a class are detected. A point-of-care UDT for a particular drug class (e.g., benzodiazepines or opioids) should not be assumed to include all possible drugs within that class. Test strip cut-offs should also be noted, as cut-offs can differ based on test settings (e.g., for medical monitoring, opiates have a standard cut-off of 300ng/mL, while the standard cut-off for workplace testing is 2000ng/mL).
A5.3 Confirmatory Testing
Laboratory confirmatory testing using gas-chromatography/mass spectrometry or liquid-chromatography/mass spectrometry provides greater sensitivity, specificity, and accuracy compared to immunoassay-based testing. Confirmatory testing can determine the presence of specific drugs, particularly semi-synthetic and synthetic opioids. As such, confirmatory testing can be used to identify drugs that are not included in immunoassay panels or are not detectable in immunoassay panels (e.g., tramadol)494 and it is useful when a patient is prescribed more than one opioid or is prescribed an opioid that has active metabolites.495 In addition, it can be used to resolve cases of false-positive results.496
Confirmatory testing is only covered through MSP in cases in which the presence of the drug would significantly impact the clinical management of the patient. Because confirmatory testing is expensive, it should only be requested when clinically indicated and when accurate test results are required to make important treatment decisions.
Availability, cost, and general processes for requesting UDT for specific substances should be confirmed with local laboratory services. Clinicians must specifically indicate confirmatory testing after a positive test result on the laboratory requisition, otherwise an immunoassay-based UDT will be performed as the default option.
The results of confirmatory testing must be interpreted cautiously, given that some opioids have active metabolites.495 For example, the presence of morphine according to confirmatory testing may be due to the metabolism of codeine, an over-the-counter opioid, rather than heroin or a non-prescribed opioid.495,496
A5.4 Slow-release Oral Morphine Urine Drug Testing
For patients treated with slow-release oral morphine, standard point-of-care opiate test strips and panels will be positive for morphine metabolites. Patients may have a positive UDT result for hydromorphone due to high morphine levels ; however, this does not necessarily indicate hydromorphone has been taken. In addition, it is impossible to distinguish unregulated heroin use from prescribed slow-release oral morphine using these tests.496 Clinicians can consider using specific point-of-care UDT for fentanyl to assess unregulated opioid use as needed to supplement clinical assessment and further patient–clinician discussion of ongoing substance use. LifeLabs and other local or hospital laboratories are able to perform confirmatory testing that can distinguish between unregulated heroin and prescribed SROM.
Mass spectrometry can distinguish between heroin, acetaminophen with codeine, and SROM as follows:
- Heroin: variably high morphine, 5–10% codeine, heroin metabolite 6-acetylmorphine (6-AM) may be present
- Acetaminophen with codeine (Tylenol #3): high codeine, relatively low morphine
- Slow-release oral morphine: very high morphine, trace levels of codeine (i.e., <50 mg/mL)
- These data may not be reported unless specifically requisitioned for individuals on SROM, point-of-care urine drug tests will be positive for the morphine metabolite and it may be difficult to distinguish on UDT between unregulated heroin and prescribed slow-release oral morphine
- However, the prevalence of fentanyl makes this less clinically important, as not many people in BC are using heroin alone if they are using unregulated opioids
A5.5 Urine Drug Testing and Virtual Care
Virtual care (e.g., telehealth, video conferencing software) is increasingly being used in OUD care. This can help reduce barriers for individuals who have to travel to see their prescriber (e.g., in rural and remote locations). It is important for clinicians to consider each patient’s circumstances when ordering UDT through virtual health. Clinical judgement should be used to determine when virtual UDT is appropriate and necessary, prioritizing patient safety and the avoidance of unreasonable barriers for patients.
If UDT is clinically indicated, there are several options for clinicians to consider when ordering UDT for patients through virtual health.
- Clinicians can request that the patient present to a local laboratory to provide a urine sample.
- Patients can be directed to a clinic location that has staff available to conduct a UDT and the prescribing clinician can then follow up on the results with the patient.
- If the patient is staying in a shelter or supported housing, the staff in the shelter may be able to conduct the UDT and support the patient to connect with the prescribing clinician.
- Clinicians can also use collateral sources (e.g., Meditech, Cerner, or CareConnect) if a patient has recently had a UDT ordered by another clinician.
The above appendix was developed to support clinical practice using a different methodology from the process utilized for the main body of the guideline.
The clinical guidance provided in the appendix has been derived through guideline committee consensus following iterative discussions in reference to existing evidence and national and international evidence-based clinical practice guidelines.
The content presented in the appendix is also informed by the opinion of expert reviewers, personal communication with study authors, and a review of position papers and practice bulletins issued by recognized addiction medicine professional organizations and authorities. In addition, where appropriate, Health Canada-approved drug product monographs, and previous and current guidance from the College of Physicians and Surgeons of BC (CPSBC) and Health Canada were consulted to ensure compliance with provincial and national safety regulations and standards for practice.