Practice of Medicine


Keeping Up with the Times: Can Urine Drug Screens Be Effective in an Ever-Changing Landscape?

In this episode, Steve Adubato, PhD, speaks with Christopher Holstege, MD, chief of the division of medical toxicology and professor of emergency medicine and pediatrics at the University of Virginia and a member of the medical faculty at MagMutual. Dr. Holstege provides important information about urine drug screens, including their history, their ability to keep up with the latest synthetic drugs, whether they can be beat, and what additional testing may be necessary in acute overdose situations. Dr. Holstege also discusses the recent policy changes coming from the DEA on the X-Waiver program for prescribing buprenorphine.

Release Date: 8/23/2023; Recorded Date: 3/7/2023

Please note: This podcast was originally a production of MDAdvantage, which is now part of the MagMutual family of companies.

Podcast Transcript

ADUBATO:  Hi, everyone. Welcome to the MDAdvantage podcast. This is Steve Adubato.  MDAdvantage is proud to now be a part of the MagMutual family. MDAdvantage physicians and their practices will continue to receive exceptional protection and support now backed by the strength and stability of MagMutual. Our podcast is honored to be joined by  
Dr. Christopher Holstege, who is chief of the division of medical toxicology and professor of emergency medicine and pediatrics at the University of Virginia, and a member of the medical faculty at MagMutual. Doctor, great to have you with us again.    

HOLSTEGE:  Steve, thank you. It's great to be here.   

ADUBATO:  For those who may have missed your introduction last time, tell folks a little bit about your background in toxicology.    

HOLSTEGE:  Yes, I'm a medical toxicologist. I work at the University of Virginia. I care for all the poison patients here and I have 48 other hospitals that are covered through our poison center. 

ADUBATO:  And what is your very important role at MagMutual?   

HOLSTEGE:  Yes, I have worked with MagMutual on a number of things, including some of these educational sessions trying to get some of the information out to make sure that our clinicians keep our patients safe. 

ADUBATO: Dr. Holstege, I'm going to get into this question. You were saying before we got on the air for the podcast that this is a confusing and important issue. We’re talking about urine drug screens. What are urine drug screens, first, and why is this topic so important?   

HOLSTEGE:  Urine drug screens are what are known as immunoassays that help to determine whether or not there is a substance in your urine. Specifically, the first drug screen that was made was really looking for things such as morphine metabolites, PCP, amphetamines, marijuana and cocaine. So you can have immunoassays that actually screen the urine to determine whether or not they are present there. 

ADUBATO:  What is the history behind urine drug screens? 

HOLSTEGE:  The history is fascinating. In the 1980s, there was a Prowler crash on an aircraft carrier. When that occurred, a number of the crew on that aircraft carrier during the autopsies were found to have illicit substances in their system. That led to an extensive testing of military personnel and a drug testing program by the military, which President Ronald Reagan liked. President Reagan decided to sign an executive order requiring testing of all federal employees with urine drug screens, and that executive order then really led to testing more broadly, to private industry, academia and other places.   

Now, if you consider that the immunoassay system that was developed at that time and the five main drugs that I mentioned, that was back in the 1980s. Things have really evolved since that time, and there are just a tremendous amount of substances being used and misused now in society.    

ADUBATO:  Dr. Holstege, let me try this. I'm curious about how these tests are keeping up with the fact that there are synthetic drugs, newer drugs that are now in existence that were not in existence when this test was created. Dr. Holstege, how are these tests dealing with recognizing the synthetic and newer drugs?   

HOLSTEGE:  They're not. That's the problem. So, for example, consider the opioid class. Certainly they pick up heroin, which gets metabolized to morphine and the test looks for morphine metabolites. That was certainly present and prevalent in the 1980s, and still are to this day. But now we also have fentanyl and fentanyl analogs. We have other opioids, even opioids that are from the pharmaceutical industry. Methadone is not picked up by the opiate assay. Tramadol, hydrocodone, oxycodone. It depends on which immunoassay you're using. So there is a plethora of opioids that may not be picked up by just that specific one.  Add to that the fact that we're seeing synthetic cannabinoids. Those are not picked up.   

ADUBATO:  Say that again, Dr. Holstege. 

HOLSTEGE:  Synthetic cannabinoids, or the substances that are agonists at the cannabinoid receptor where we think marijuana works. So many of those came out in 2009. 2010 is when we really had a large outbreak of K2 and Spice. They are known by their slang names, They were not picked up on urine drug screens. We also had a lot of plant-based substances, like kratom and salvia divinorum. There's a whole host of substances that are not picked up by the urine drug screens that are commercially available.   

ADUBATO:  So based on what you're saying, Dr. Holstege, is it really possible (and I don't want to use the word probable because I don't know the statistics on this) for someone to beat the system? 

HOLSTEGE:  Yes, and part of the challenge is: What is the system? What is the drug screen that is being utilized, and is any confirmation screening being done? So in smaller hospitals that I cover, critical access hospitals typically do just amino assays. At the University of Virginia, where I work, we actually have confirmation by what's known as chromatography. There's a number of different ways that it is done, but we have more extensive testing. But even our testing that we typically do can miss many substances, and that's where the challenge is.   

The Internet has opened Pandora's box. In 2013, the United Nations Office of Drug and Crime came out with a statement that for the first time since the 1960s, since its existence, they had lost control of the synthetic drug market. There are so many new synthetics coming out and so rapidly. We can't keep up, and none of those are being picked up by the screens. I see this routinely in my practice, and that makes it very challenging. It makes it challenging for law enforcement, for state forensics and for us in medicine to know exactly what our patients are taking. 

ADUBATO:  I want to follow up on this question. So say, doctor, that a patient suffers an acute overdose. What additional testing can and should be performed to identify the substances in that patient's system? 

HOLSTEGE:  I always teach my class and at the bedside, that the first important thing is the physical exam. The second is what other laboratory tests do we have to clue us in to what they may have taken. That includes the electrocardiogram. And then three, we can do the drug screen to get some idea of what might be there for common substances. But if we really need to do more analytics, we may have to go to a more sophisticated lab, and there are some commercial labs that are very good that can do more sophisticated analytics. 

Now, in the treatment of my patients when they overdose, does it really change management? It doesn't, and we don't necessarily have to do that additional testing. But there are cases, for example, for public health surveillance, where I might have a clustering of patients that come in and I want to send off for more extensive analytics. Or, for child abuse, I may end up doing more extensive analytics if I am worried what the child may have been given or gotten into and their home environment. As a clinician, we just need to realize the drug screens are limited. They're not going to pick everything up, and just because there isn't something positive on the drug screen does not mean that there's not an illicit substance or a new emerging substance there. 

ADUBATO:  I have a final question, about the DEA changing policies with the so-called X waiver. But before I do that, I did not ask you, Dr. Holstege, in the first interview we did on medication errors. Your fascination and your passion for the field of toxicology comes from where? 

HOLSTEGE:  Chemistry in undergrad. I think as physicians and the other clinicians, we are allopathic and we are using medications to treat patients. It's exceedingly important that we know the medications and what they're doing to the human body when we're giving them. As a physician, I don't want to do harm. I want to make sure that we're giving the medication as a benefit, and that's really where my fascination is with it. If we're going to give substances to people, we need to make sure how they are working and that it's a benefit to them. And that's where my teaching comes, too. 

ADUBATO:  My final question. So I mentioned the DEA (the Drug Enforcement Agency). First of all, what's an X-waiver, what has changed and why is it important? Sorry to ask a multi-part question. What is this X-waiver?   

HOLSTEGE:  When buprenorphine came out, the X-waiver program really allowed clinicians to prescribe it to those who have an opioid addiction to start their treatment. There was a special waiver that allowed us to be able to prescribe it, and it was somewhat of a barrier to be able to prescribe buprenorphine to our patient population. 

ADUBATO:  And this matters to our physicians listening right now, because why?    

HOLSTEGE:  Well, we're seeing a pretty significant opioid epidemic that's expanding, and we see the importance of buprenorphine for treatment to start addiction treatment early. So now, with this more open ability to prescribe buprenorphine, we can now initiate treatment more easily. It doesn't limit or cap the patients to whom we are prescribing buprenorphine, or how we're treating them. There are some clinicians who are actually managing quite a few patients right now with opioid addiction and using buprenorphine. It's one of the ways to try to combat right now what we see as an escalation with the opioid epidemic, which is pretty profound. It's leading to a lot of deaths, and certainly in my practice I see opioid overdoses nearly daily now.  

ADUBATO:  Dr. Holstege, this is incredibly important information. I'm glad you've shared that with our podcast audience, and so I want to thank you very much. We appreciate it.   

HOLSTEGE:  Thank you, Steve.   

ADUBATO:  On behalf of the teams at MDAdvantage and MagMutual, this has been Steve Adubato. We thank you so much for listening. Check us out next time.  


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