Association of random and observed urine drug screening with long-term retention in opioid treatment programs

Abstract

Background: In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs.

Methods: This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects.

Results: 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship.

Conclusion: Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.

Keywords: Methadone; Methadone policy; Person-centered treatment; Retention; Stigma; Urine drug screening.

Figure 1:

Directed acyclic graph (DAG) for the hypothesized relationship between urine drug screening (UDS) modality and long-term retention in treatment. Minimum sufficient adjustment sets tested were a) clinic philosophy and clinic resources* or b) additional services, clinic philosophy, and UDS frequency. Figure created using DAGitty (Textor et al., 2016). *indicates primary model used in fractional logit regression modelling

Figure 2:

Percentage difference in Client Retention ≥1 Year by Clinic Modality of Urine Drug Screen Differences & 95% Confidence Intervals estimated with fractional logit regression. Referent = Clinics with <90% Random and <90% Observed UDS (Urine Drug Screen). Adjusted models include: clinic philosophy and clinic resources.

Figure 3:

Percentage difference in Client Retention ≥1 Year by Clinic Modality of Urine Drug Screen: stratified by clinics with versus without a discharge policy for positive urine drug screens Differences & 95% Confidence Intervals estimated with fractional logit regression adjusted for: clinic philosophy and clinic resources. Referent = Clinics with <90% Random and <90% Observed UDS (Urine Drug Screen).