Charlotte Van Hale, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Rachel Gluck, MD PGY-4 General Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Yi-lang Tang, MD, PhD Associate Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia Addiction Psychiatrist Substance Abuse Treatment Program Atlanta Veterans Health Care System Decatur, Georgia
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Acknowledgments The authors thank Jennifer Casarella, MD, and Karen Hochman, MD, of Atlanta VA Medical Center, and the Department of Psychiatry and Behavioral Sciences, Emory University, for their comments on this article.
Though addiction specialists often advise complete abstinence from all substances, including alcohol, cannabis, and tobacco, the harm-reduction model emphasizes “meeting patients where they are” in terms of continued substance use.37 If a patient can reduce their substance use or abstain from some substances while continuing others, these accomplishments should be acknowledged.
For patients who continue to test positive for illicit substances (>3 instances) without a clear explanation, schedule an appointment to re-educate them about buprenorphine treatment and reassess the patient’s treatment goals. Consider changing the current treatment plan, such as by having more frequent follow-ups, increasing the dose of the buprenorphine for patients whose cravings are not sufficiently suppressed, switching to another medication such as methadone or naltrexone, or referring the patient to a higher level of care, such as intensive outpatient or residential treatment.
9. What should I do if the results indicate abnormal levels of buprenorphine, norbuprenorphine, and naloxone?
When urine buprenorphine, norbuprenorphine, or naloxone levels appear low or the results indicate a likely “spiking,” clarify whether the sample tampering is due to poor adherence or diversion. Similar to dealing with a positive result for substances of abuse, ask the patient what they expect to find in their urine, and discuss the results in a nonjudgmental manner. Patients who admit to difficulty following their medication regimen may require additional psychoeducation and motivational interviewing to identify and address barriers. Strategies to improve adherence include setting an alarm, involving the family, using a pillbox, or simplifying the regimen.38 A long-acting injectable form of buprenorphine is also available.
If you suspect diversion, refer to your clinic’s policy and use other clinical management skills, such as increasing the frequency of visits, random pill counts, and supervised medication administration in the clinic.39 If diversion occurs repetitively and the patient is not appropriate for or benefiting from buprenorphine treatment, it may make sense to terminate treatment and consider other treatment options (such as methadone or residential treatment).39
10. What should I do if a patient disagrees with laboratory findings?
It is common for patients to disagree with laboratory results. Maintaining an attitude of neutrality and allowing the patient to speak and provide explanations is necessary to ensure they feel heard. Explanations patients frequently provide include passive exposure (“I was around someone who was using it”) or accidental ingestion, when a patient reports taking a medication they were not aware was a substance of concern. In a calm and nonjudgmental manner, provide education on what leads to a positive drug screen, including the possibility of false positive findings.
