Urine Sample

Urine Drug Testing on Suboxone

A recent exchange with a reader:

I have been on buprenorphine for 5 yrs.  Recently my doctor stated that my u/a t looked like I have been ‘loading my meds.’  He said my levels where ‘backwards’ and that would happen if I took just a few doses just before my appt.   My doc had me come back in two weeks to go over my next u/a, and again it came back funky.  So my doc starts having me take my meds in front of the nurses on a daily basis.  Two weeks later with supervised u/a’s, my urine comes back the same.  My doc looked perplexed but kind of ignored the results like I was still doing something to mess with the results.  I had to come in again for another urine test and it finally came back normal.  My numbers were fine after that, and all was good until last week.

I went to my normal monthly check up and the u/a showed NO buprenorphine in my system.  My doc looked at me like I am the biggest liar.  I am perplexed.  I am taking my meds daily.  I don’t know what is going on and I need to figure it out soon before my doc kicks me out of the program. What could be wrong with the test, that is says that I have no buprenorphine in my body?

My response:

There are several directions we could go with this issue.  One aspect is whether it is always fair to believe the results of drug tests over the word of our patients.  I understand the reasons for testing, but I think that doctors sometimes lose the forest (the patient’s addiction problem) on account of the trees (quantitative testing).  This patient has been on buprenorphine for five years; I would hope to have sufficient trust established with patients after that period of time, such that the lab results wouldn’t be seen as the only answer.  There can be problems with any laboratory test.  Drug tests are one tool– not the ultimate arbiter of truth.

Most people metabolize buprenorphine a certain way, leading to the build-up of a chemical called norbuprenorphine.   I assume that by ‘backwards’ the doctor is saying that the buprenorphine level is higher than the norbuprenorphine level, whereas with daily use of buprenorphine the opposite would be true. As your doctor said, if a person takes one dose of buprenorphine and is tested an hour later, buprenorphine would be present, with only small amounts of the metabolite norbuprenorphine.

Urine tests for any substance are affected by many variables, including the actions that different parts of the kidney have on certain substances.  Some substances are concentrated at the kidneys, making urine testing more sensitive than blood testing.  But other substances might be re-absorbed by the kidneys to a varying degree, depending on hydration status, nutritional and dietary factors, hormonal factors, and personal genetics.  Because of concentration and reabsorption effects, the drug levels from urine tests are not accurate indicators of drug levels in the bloodstream.

In addition, the metabolic pathways for certain substances might be changed by the presence of other substances.   For example, if the enzyme that turns buprenorphine into norbuprenorphine is blocked or occupied by other substances, the pathway may change such that metabolites other than norbuprenorphine are formed—- including metabolites that won’t show up unless they are specifically tested for.

I asked the patient:

Are you taking any other medications?  Are you able to get the actual lab results showing the details of the test?

She replied:

I thank you for responding to me.  I am on many medications because I have fibromyalgia among many other things.  My list of meds:

Prozac 20 mg; Provigil 200 mg; Clonidine 0.1 mg 4x’s a day; Amlodipine 5mg once a day; Nabumetone 500mg 2x’s a day; omeprazole 20mg once a day; Ambien 10mg per day; Relpax when I have a migraine; Buspirone 10mg about 2x’s a day; Subutex 16 mgs per day. I also take diphenhydramine 50 mgs at bedtime when needed to help sleep, and Vitamin D3-1000 iu once per day.  I take this because my blood tests showed it was low.

I asked to see my results and my doctor told me that I didn’t need to see them; that he had told me what it said and that it should be enough for me to know.

The receptionist in the office is getting the number to the lab for me.  Do you have any questions that I should ask?  What should I know?  I am going to ask for a copy of my labs at my next visit.  I am nervous that my doc will just stop prescribing.  This medication has saved my life and I don’t know where I would be without it.  Please help me make my doctor believe in me again.  I know that is a lot to ask but I’m in trouble.  Where can I turn?  There aren’t any Suboxone docs in my area taking new patients.

(A couple thoughts)

Over my 20 years as a physician, I’ve come across times when tests were mistakenly trusted over the word of patients.  At a maximum security prison for women where I worked as a psychiatrist, for example, many women were disciplined for diverting clonazepam, until a call to the lab revealed that testing wasn’t reliable for that medication.

Over time, we learn more and more about how the metabolism of one medication impacts other medications.  One such interaction was apparent in this person’s case.

My comments:

The most obvious interaction from your list is that Provigil is an ‘inducer’ of cytochrome 3A4, the enzyme that breaks down buprenorphine.  A person taking Provigil develops greater amounts of that enzyme in the liver, which results in faster metabolism of buprenorphine.  The first step in metabolism of buprenorphine is conversion to norbuprenorphine, so levels of buprenorphine and norbuprenorphine would be affected by Provigil, in unpredictable ways.

From the program that I use to search for interactions:  buprenorphine ↔ modafinil

Coadministration with modafinil (the racemate) may decrease the plasma concentrations of drugs that are substrates of the CYP450 3A4 isoenzyme. Modafinil and armodafinil are modest inducers of CYP450 3A4, and pharmacokinetic studies suggest that their effects may be primarily intestinal rather than hepatic. Thus, clinically significant interactions would most likely be expected with drugs that have low oral bioavailability due to significant intestinal CYP450 3A4-mediated first-pass metabolism (e.g., buspirone, cyclosporine, lovastatin, midazolam, saquinavir, simvastatin, sirolimus, tacrolimus, triazolam, calcium channel blockers). However, the potential for interaction should be considered with any drug metabolized by CYP450 3A4, especially given the high degree of interpatient variability with respect to CYP450-mediated metabolism. Pharmacologic response to these drugs may be altered and should be monitored more closely whenever modafinil or armodafinil is added to or withdrawn from therapy. Dosage adjustments may be required if an interaction is suspected.

That is just one of many possible interactions. When a person takes multiple medications, there are often other, less predictable interactions.  Some medications also interfere with the testing of other medications.  You may know that there are chemicals available on the internet to block the testing for certain compounds;  some medications do the same thing.

She answered:

I can’t thank you enough for even responding to me……  You are a very kind man!  I hope this helps me.  I am very scared my doctor will take me off my meds.

But then she wrote again:

I wanted to send you an update.  My doctor wouldn’t even look at the conversation we had.  I guess for whatever reason, he refuses to look deeper into the issue.  It is sad when a doctor has had a patient for over 5 yrs and he won’t look into this further.  I don’t ever have dirty u/a’s.  I don’t drink, I don’t smoke marijuana, I only take what he prescribes to me.  He refuses to look further into the matter so much that it is clouding his judgment.  He won’t even test me another way.  He states urine test are the most accurate but there is something wrong because I know that I take my meds.  He refuses to do another supervised dosage week because he doesn’t have the manpower.  

I know in his eyes that all I am is a drug addict but I deserve respect. Why would a man who believes in science have such a closed-minded view?  I would think he would at least want to discover what is happening.  There has to be more patients like me that are being thrown away because we don’t fit a certain mold.  When he throws me out of treatment on Monday, I have nowhere to go.  There are large waiting lists to see a doctor in my area. I can’t go back on the streets for medication.  I don’t have any of those friends left in my life.  I am in so much trouble.

I don’t know why I felt the need to vent to you but my hope was to find one person that believes me in hopes that this problem could be addressed someday, somehow.  Thank you for listening.  I do appreciate it.

One thought on “Urine Drug Testing on Suboxone”

  1. I recently had a very similar experience. I’ve been in a program since March 2012, and at the start of 2014 my wonderful doctor decided as a result of the changes to his private practice with Obamacare, he was closing the office and moving out of state to work for a PMO. Scrambling to find a new doctor (who knew only 3% of them can offer programs across the US…) and getting rejected by a “Behavioral Healthcare center” because I was “recovered” and “needed to relapse” to enter their program, I found a doctor that almost seemed too easy after failing time and time again in making phone calls to find a dr taking new patients. I have been with this doctor now since February 5 (today is March 5) and have seen the nurse practitioner 4 times. 3 of which, I sat for an hour and a half before even getting pulled in for my tox screen. What was different here, was that the nurse didn’t come in with me (everywhere else I’d been…outpatient therapy, my previous doctor) a nurse came with you to the bathroom. When done, you slide it through a magic door. Anyway…this last appointment I told the nurse practitioner that since I started weaning in Oct 2012 (dropped from 16mg to 12mg a day) I needed to come clean and let them know that I’ve been buying from someone who doesn’t take theirs to supplement the difference. In recovery you learned to be HONEST OPEN AND WILLING, so I thought I was doing the right thing. This experience with the NP has been terrible as I find her to act very condescending. Like I said 3 of the 4 appointments were over 3 hours long and that wasn’t because I was getting cared for – it was a result of wait time and CONSTANT interruptions where co-workers come into the consult room – knock, open the door without invite, apologize for the interruption (why when you know this is a lie…) then direct a question to the NP, and almost every question is about a patient that had previously left her office that someone else was asking specific questions about…and I hear this NP give very “tonal” answers, sometimes elaborate on specifics of why she is treating the individual badly (like they are deserved of it) and never turns to apologize to me for having the interuption. So, after the confession and 2 interuptions, she comes back to focus and pulls my records up on the computer, and starts to show me on screen the results of the past 3 toxes I had received. There was one from 2/11 that read POSITIVE for Ritalin. Mind you- my tox screens for the past two years have NEVER been dirty. I didn’t know what this meant, and this was the first time I’d ever viewed this detail. She starts to also indicate that my levels of suboxone are low. I retort with well of course at the start I would have been low, I had no script and was in a 3 day withdrawal. She explains that there are 2 levels on the screen- one for the immediate and one for the “over time” and she indicated to me that this was way too low, indicating that it was showing like I use less than 4mg a day. The reason I’m freaked is not only because I’ve never had a bad tox, but their policy is to go to weekly visits, she indicated I needed to start participating in outpatient counseling as it was considered relapse, AND if it continues they will either reduce my script by half, or eject me from the program. I had asked her if she had a history of my tox screens. She indicated (in her condescending voice) no, we only received one from Dr. C and “they” (she consistently uses the word “they” when I know it is her making the recommendations) are considering not taking new patients who were previously with Dr. C because “many ” of his former patients are coming back with bad toxes like having cocaine and other street drugs in their toxes, and that “he must have been performing his toxes on his own”. I didn’t come back with a retort even though I have bills from the diagnostic labs proving the previous Dr sent the toxes out. In fact, I had an argument with my insurance company at one point because it was his practice to perform “only” his own pregnancy test onsite and my insurance company would not cover that cost because “he” was performing it.
    Anyway, I told her I didn’t know what Ritalin was and therefore how could I have taken it? She said (Looking down her nose at me, again in the cocky condescending voice) well, you just admitting to getting suboxone on the street. I said it wasn’t necessarily off the street, AND the packages were sealed. She just ignored me and continued to type into her computer. There was no way she was hearing it. I kept asking more questions about the results of this test, and was either ignored or sneered at where she would say well, I don’t have a list of other drugs you are taking on a regular basis. I said what do you mean? My primary had supplied the information that he had prescribed a Clonezepam script and you made me get a letter from him saying he would not prescribe it anymore (this script was for the period in between when I was out of Suboxone and looking for a doctor to help me through any withdrawal symptons along with the aspirin, pepto bismol that I had taken during that time. I asked if I needed to tell her if I took excedrin migraine or aleve naproxen) for when I had a headache/toothache. She said condescendingly again “do you take it daily?” I said when I’ve got a headache or toothache I take it. When I kept asking questions about it, she told me that I needed to call Quest Diagnostics to get the information directly from them. At that point, we wrapped up the 3 and half hour session (oh there were 2 more intrusions during that time), I made my next appointment and left their facility and drove directly to the outpatient “Behavioral center” that I had previously tried to get into… Now that I had (and I quote) “relapsed” I shouldn’t have a problem getting into the place I wanted to go to in the first place. I went through the induction process again (a month later) and after talking to the counselor there telling her why I was there, she seemed a bit more sympathetic… I think she was tending to be cautious on showing her true feelings and I didn’t blame her for that, seeing I was a new person coming into a program.
    In any case, on my way from one appointment to another yesterday, it dawned on me that I was on Prednisone and Fluticasone nasal spray during this period of time. At the end of January, I had what I thought was a toothache but ending up being water on the ear – a problem I’ve been dealing with since August thinking it was a toothache I couldn’t afford to fix. My doctor prescribed 7 days of steroids, and a month of the nasal spray and referred me to a specialist (because the water is in their deep…still haven’t seen the specialist on this). The NP never brought up the steroids, and I had forgotten about them as well which makes me wonder if she ever put that information in the system when I had my induction appointment on Feb 5th (which, by the way was 4 hours long and had 8 interruptions along with a period of what I believed to be her taking her lunch while I sat in the consult room (3×3…tiny) because after an hour of being in there by myself and the office sounding extremely quiet for a long time, she was picking her teeth.
    I started researching today because not only am I horrified by the “bad tox” but the fact that now I have to shell out money for weekly appointments, weekly scripts, weekly gas money (their office is across town—not close at all to me) and I’m fighting to survive now as a female bringing home the bacon for my family.
    I’m printing out what I find and hope that I will have a case/point but I’m fearful of the unknown at this point. I feel like this woman hates her job, looks at all of us as “scumbags”, there is definitely no “care” in Healthcare at this facility. Did I mention that at my first appointment the Dr. came in and introduced himself for 10 seconds and said… “Don’t worry if you don’t see me at your appointments, know that I am involved in every way as part of your program here”. I should have seen that as a red flag. Unfortunately, we don’t have much of a choice in selecting the healthcare provider, I was lucky to have made the choice in getting with my previous one…. he was old school but not “old”… meaning he made eye contact with you, discussed with you your challenges in the recovery process not just face to face but eye to eye and wait for this…. updated the info on his laptop at the END OF THE SESSION. Point being, his face wasn’t ever buried behind his laptop while delivering ‘care’. He was also a primary care physician who would not prescribe opiates to his patients for any reason. I had a friend who had their elderly, sickly (cancer stricken) mother brought up from down south and needed primary care. Dr. C would not prescribe her ANYTHING she was getting before and told her that if she wanted to see him, she needed to understand he wasn’t giving her these drugs. The place I go to now…. the people getting opiates for pain are sharing the same waiting room with those struggling to get off the damn stuff. I loved that Dr. C wasn’t a hypocrite about caring for his patients.
    One last thing.. I’ve attempted to contact the diagnostics center who performed the testing and it’s like pulling teeth to get to the right person and/or get anyone to answer the phone. The NP didn’t give me any info on how to go about it, and from looking at the testing centers website, it looks like they need to get permission from the dr to release any information to me in the first place… I’m almost feeling like the NP said this just to shut me up.

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