Drug testing

Urine remains the most versatile biological fluid for drug testing and has the advantage of indicating drug use over the past several days. As well as being physically non-invasive, drugs are present in relatively high concentrations and large samples can quickly and safely be collected. Heroin remains detectible in the urine for 3-4 days.

Oral fluid tests may be considered as an alternative, although drugs are present in lower concentrations and the sample size is usually much smaller than for urine. The detection window for oral fluid testing is normally 24–48 hours for most drugs, so only very recent drug use can be detected. 

How long drugs remain in the urine depends on factors such as dosage, frequency of abuse, the sensitivity of the test carried out and individual differences in drug metabolism.

Of the most common drugs of misuse, cannabinoids and benzodiazepines stay detectible in urine for the longest; 7-30 days and 3-6 weeks respectively.

Resource:

Drugs.ie. How long do drugs stay in your system?

Resources

• Drugs.ie  How long do drugs stay in your system?

• NICE. Drug Misuse in Over 16s: opioid detoxification. CG52. 2007.

• Public Health England. Alcohol and drug misuse prevention and treatment dependence. Updated 2024.

FRAMES

NICE suggests that brief interventions can be used as psychological therapies in drug misuse. There are several models that can be used for brief interventions and motivational interviewing including the FRAMES model. This utilises the principles of feedback, responsibility, advice, a menu of options, empathy, and self-efficacy. The other options are all different models used in the teaching and analysis of consultation skills.

Resource:

Lucas J. Dependence on prescription medication. InnovAiT 2022; 15(4): 202–208.

FRAMES is a brief motivational interviewing tool that stands for:

• F – Feedback on risk and harm

• R – Responsibility of the patient to change

• A – Advice on how to change consumption

• M – Menu of strategies to change behaviour

• E – Empathic and non-judgmental manner

• S – Self-efficacy to raised confidence to change behaviour

Both the DAST-A and CRAFFT tools are used to screen for substance misuse in adolescents. The PHQ-9 tool is used to screen for depression and CURB-65 is used to estimate pneumonia severity in adults. DAS 28 Disease Activity Score Calculator for Rheumatoid Arthritis

Resource:

Hernandez Sanchez I. Young people and substance misuse. InnovAiT 2018; 11(11): 601–607.

Psychosocial interventions for drug misuse

A 28-year-old man attends your surgery. He has been injecting heroin for a number of years and his habit has been increasing lately. He is ambivalent to seeking help for his opioid dependence and feels he has it under control. Despite this, you spend some time with him, and he agrees to a same day referral to the local community addiction team for further discussion.

Which of the following psychosocial interventions are NOT RECOMMENDED in the management of an individual with addiction problems?

1. Using privileges such as giving take home methadone

2. Using incentives such as vouchers to help with compliance

3. Giving information on self help groups that use 12-step principles

4. Opportunistic brief interventions looking at individual motivation

5. Using incentives such as money to help with compliance

Opportunistic brief interventions focused on motivation should be offered to people in limited contact with drug services (e.g., if attending a needle exchange or primary-care setting).

Individuals should be offered information about self-help groups. Self-help groups will normally be based on 12-step principles, e.g., Narcotics Anonymous and Cocaine Anonymous.

NICE recommends that drug services should introduce contingency management programs to:

1. Reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment, e.g., offering incentives (usually vouchers that can be exchanged for goods or services of the service user’s choice, or privileges such as take-home methadone doses.)  Contingent on each presentation of a drug-negative test, e.g. free from cocaine or non-prescribed opioids. The frequency of screening should be set at three tests per week for the first three weeks, two tests per week for the next three weeks, and one per week thereafter until stability is achieved. If vouchers are used, they should have monetary values that start in the region of £2 and increase with each additional, continuous period of abstinence.

Urinalysis should be the preferred method of testing.

2. Improve physical healthcare of people at risk of physical health problems (including transmittable diseases) resulting from their drug misuse, material incentives (e.g., shopping vouchers of up to £10 in value) should be considered to encourage harm reduction.  Incentives should be offered on a one-off basis or over a limited duration, contingent on concordance with or completion of each intervention, in particular for:

• Hepatitis B/C and HIV testing

• Hepatitis B immunisation

• Tuberculosis testing

Resource:

NICE. Drug Misuse in Over 16s: psychosocial interventions. CG51. 2007.

Driving

Any patient who persistently uses or is dependent on amphetamines, should be advised to notify the Driver and Vehicle Licensing Agency (DVLA). This will lead to licence refusal or revocation. Group 1 (normal car) licences may be reinstated after a minimum of 6 months free of amphetamine use has been attained.

Resources:

Department for Transport. Drug Driving and Medicine: advice for healthcare professionals. 2014.

Scottish Government. Drug Driving and medicine: advice for healthcare professionals. 2019.

You see a 47-year-old lorry driver who has had lower back pain for some time. He has been using 10mg diazepam four times a day from his friend for the past 10 months. He refuses to engage with attempts to reduce the medication and says he will continue taking them. You advise him not to drive and to inform the Driver and Vehicle Licensing Agency (DVLA).

How long is his licence likely to be refused or revoked for? 

1. 1 year

2. 6 months

3. 18 months

4. 3 years

5. 3 months

The non-prescribed use of benzodiazepines constitutes persistent misuse or dependence for licensing purposes. In these situations, patients need to be advised not to drive and to notify the Driver and Vehicle Licensing Agency (DVLA). If this condition is confirmed, their licence will be refused or revoked for a minimum of 3 years (which must be free of misuse or dependence).

Resource:

Cary AE. Substance misuse and driving. InnovAiT 2022; 15(6): 343–348.