Volume XV, Issue II - July 2021

From:  David T. Jones, Director
Division of Substance Use Prevention and Recovery

IDHS/SUPR Practice Recommendations for Drug and Fentanyl Testing

The Illinois Department of Human Services/Division of Substance Use Prevention and Recovery is pleased to present our Practice Recommendations for Point of Care Drug Testing, Fentanyl Screening in Clinical Addiction Medicine, and Fentanyl Screening as a Harm Reduction Tool.

Drug Testing and Screening in Treatment

Drug testing refers to the detection of the presence of a substance from a given biological sample, such as blood or urine, within a given window of time. Drug tests are valuable tools that inform providers about a patient's substance use, but their clinical utility depends on whether they are appropriately used in treatment and within the harm reduction framework. It is critical for practitioners to understand what information a drug test can and cannot provide. The "window of detection" varies across sample and substance type and must be taken into consideration when analyzing the results of a drug test. A drug test also cannot tell you whether multiple substances were used in combination (e.g. polysubstance use) or whether one substance was consumed which contained multiple expected or unexpected components. A single negative drug test also does not provide a comprehensive picture of an individual's substance use history and does not rule out history or presence of substance use disorder. Making determinations about the presence of a substance use disorder involves a more comprehensive assessment of a person's relationship to a substance/s including assessment of impacts on functioning, extern and pattern of use, indicators of physical/behavioral dependence, health impacts of use, and motivation for change. Similarly, a single positive drug test is not indicative of a substance use disorder as a single test alone does not measure patterns of use over time.

Using drug testing measures alone is not sufficient in facilitating a diagnosis or a therapeutic discussion. Providers should be aware that false positive and false negative drug test results are possible and therefore must rely not only on the results of a test to inform clinical decisions, but also other important diagnostic information including patient history and physical exam. In order to provide a patient with both data-driven and patient-centered care, the combination of self-reported use, patient history, objective drug test results, physical examination, and biopsychosocial assessment should be used to guide the diagnosis and clinically relevant treatment options.

A positive opioid or fentanyl drug test is NOT required to diagnose a patient with an opioid use disorder (OUD), and as discussed above is not sufficient on its own for a diagnosis. Rather, clinicians should rely on the DSM-V criteria that is informed by patient interview and history in addition to physical exam findings.

Drug Testing and Patient Communication

Screenings should be used, and results should be communicated to patients as a therapeutic tool that can inform both patients and providers of measurable data to aid in evidence-based treatment planning. Providers should treat and view drug testing as a tool to initiate a therapeutic discussion with patients regarding substance use characteristics, motivation for change, and ambivalence. If a patient refuses to undergo a drug test, this behavior can be discussed as an area of focus in the treatment plan. It is not best practice or standard of care to discharge a patient or enact other punitive measures for a positive drug test or refusal to provide a drug screen. This should instead be used as an opportunity to explore the patient's goals, treatment options, and provide harm reduction strategies that are patient-centered, address safety, and reduce the morbidity and mortality associated with substance use disorders.

Upon admission, when testing and screening for the presence of substances, it is important to communicate with non-punitive and non-stigmatizing language. For example, providers should be aware of using objective, non-judgmental language such as "positive" and "negative" to describe the results of a drug test rather than "clean" or "dirty". Providers should use a positive test as a springboard for conversation and a negative test as a source of encouragement to patients.

When Should Drug Testing Occur?

Studies suggest that drug testing has the potential to improve patient outcomes and provides further information used to shape and adjust treatment plans. The American Society of Addiction Medicine's current recommendations for drug testing suggest point of care drug testing at intake. Testing upon initial assessment provides a provider with information early-on that then guides approaches to treatment and helps determine optimal placement in a level of care.

Drug testing is also recommended for ongoing treatment of addiction and substance use disorders as a therapeutic tool. Frequency of testing should be more frequent at the beginning of treatment and should be decided based on patient acuity and level of care placement, but current studies do not provide sufficient evidence on whether more frequent testing decreases substance use behaviors. Providers should consider implementing a random-interval testing schedule as opposed to a fixed schedule when possible, to avoid known non-testing periods.

It is important to note that federal regulatory changes during the COVID-19 pandemic allow the initiation of buprenorphine using telemedicine, without an initial in-person evaluation. Lab testing is typically not available during telemedicine evaluations and the lack of access to testing should not delay the initiation of buprenorphine.

Importance of Fentanyl Testing in Admission and Treatment

Drug screening in the context of opioid use is of particular importance for patient safety. With the increasing presence of synthetic opioids such as fentanyl, fentanyl analogs, or other novel synthetic opioids in the illicit drug supply, it is helpful to utilize fentanyl testing on admission and throughout treatment. While standard drug testing and screening is effective in evaluating the presence of some opioids such as heroin, it is important to note that fentanyl and other novel synthetic opioids will NOT be detected in a standard opiate immunoassay and therefore requires a separate screening test. If fentanyl testing is not available, providers should rely on patient history and exam when diagnosing and preparing relevant treatment options for opioid-related diagnoses. A positive drug test is not required for admission to OUD treatment such as withdrawal management, or reimbursement for OUD treatment services. The diagnosis of OUD, opioid intoxication, or opioid withdrawal can be determined on patient history and exam with appropriate documentation within the patient record, and can be used as criteria for admission, treatment, and reimbursement.

Fentanyl is a potent synthetic opioid that can be mixed with other drugs, such as heroin, cocaine, methamphetamine, and MDMA, which may put people who use opioids, alcohol, or benzodiazepines at higher risk of fatal overdose. Patients may be unaware fentanyl is in the illicit substances they are using, as many illicit opioids are still "sold-as-heroin" or "sold-as-dope". Providers should be aware that fentanyl will not be detected in a standard opioid drug screen and should ensure access to fentanyl-specific testing.

Fentanyl testing at both admission and during treatment management provides objective monitoring of treatment adherence and can assist providers in making informed treatment plans for patients based on patient goals, including harm reduction goals such as using less or using less frequently. Upon admission, point of care testing can inform providers of an individual's immediate specific treatment needs. Testing for fentanyl during treatment can help providers adjust and monitor the treatment plan, particularly if the patient is being treated with medication assisted recovery (MAR) such as methadone and buprenorphine/naloxone. Patients who have continued opioid use (including fentanyl) while taking methadone may require more frequent monitoring for safety (observed dosing).

Peer recovery support services and counseling services are effective tools in OUD treatment, but these services should not be a condition to receive MAR. Independent of counseling, MAR is evidence-based and best practice for OUD to saves lives.

When a patient choses counseling in combination with MAR, the treatment programs should consistently re-assess a patient's readiness for change, the goals of treatment, and treatment plan, and offer (not mandate) appropriate support services including recovery support and counseling. It is important to respect patient autonomy, focus on harm reduction, and provide patient-centered recovery support.

Importance of Fentanyl Testing in Harm Reduction Strategies

Over 90% of opioid-related overdose deaths in Cook County in 2020 involved fentanyl. An important consideration for providers is to educate patients about the use of fentanyl test strips and other community-based drug testing services to detect fentanyl and other synthetic opioids that may be in a drug sample. Evidence-based harm reduction strategies such as the use of fentanyl test strips are an important resource for individuals to use as an option to check for the presence of fentanyl in their drugs.

The use of synthetic opioids such as fentanyl is associated with an increased risk of overdose as well as increased risk of complications and death when combined with prescribed opioid agonists used in treatment. Individuals should be encouraged to engage in harm reduction behaviors to test illicit drugs and pills that are obtained or purchased from a non-medical provider for fentanyl using rapid response testing strips. Fentanyl test strips (FTS) allow people who use illicit substances to be more informed about what they are buying and using, encouraging the adoption of harm reduction behavior measures. FTS do not require a large amount of drug to effectively test and provide a result in 1-2 minutes. However, they do not provide information on how much fentanyl is in a drug nor do they detect other drugs that may be present in a sample.

In addition to providing individuals with fentanyl test strips and education on how to use them, they should also be equipped with other harm reduction resources and information on overdose prevention including the option to dispose of a fentanyl-contaminated drug, providing education on how to use and inject in a manner that mitigates risks, ensuring that the medication naloxone is supplied to the individual and training on its use is provided.

While fentanyl test strips should not be used as a systematic strategy to monitor all street drugs for fentanyl, it can be a powerful tool in helping providers educate and empower individuals how to approach uncertainty and potential unknown substances in their drug supply. When combined with overdose prevention training and provision of naloxone, fentanyl test strips can be an effective harm reduction tool for both patients and providers.

Additional Information, References, and Resources

ASAM Guidelines

Fentanyl Test Strip Brief

Fentanyl Test Strip for Harm Reduction Studies

Fentanyl Test Strip Pilot

CDC Information on Evidence-Based Drug Overdose Treatment

CDPH Health Alert Network

Get harm reduction supplies in Illinois or refer patients to treatment services

Miller, W. R., Forcehimes, A. A., & Zweben, A. (2019). Treating addiction:  A guide for professionals. Guilford Publications.