Urine Drug Testing on Suboxone

First Posted 2/15/2013

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.

15 thoughts on “Urine Drug Testing on Suboxone

  1. I have a question for someone my husband and myself have been in a Suboxone clinic for 8 months and last week we had a urine test and he tested positive for buprenorphine and negative for naloxone but my tests come out perfectly I took the strip cut so where we can come together I am wondering how this is happening please I need an answer

    • Naloxone does not always show up in urine tests in people taking Suboxone. A very small amount of the naloxone is absorbed, especially if the person is taking it properly (3% is absorbed under the tongue, but 100% is absorbed if injected IV). Naloxone ie destroyed by the body very quickly. So I would not be concerned if no naloxone appeared in urine testing. You probably metabolize the nalone a bit more slowy, or maybe your urine was more concentrated, and that’s why yours showed up but his didn’t. He should NOT be discharged for something like that!

    • One reason the answers vary is because the time varies– between individuals, and depending on the dose, how long it has been taken, and the testing methods. From the start, people metabolize buprenorphine at different rates, depending on the activity of enzymes called ‘cytochromes’. Those enzymes vary by over 100% dependinig on genetics, and they are also impacted by many medications. Buprenorphine is mostly metabolized by CYT3A4, and you can see medications that induce (increase) or inhibit that enzyme’s activity at wikipedia: https://en.wikipedia.org/wiki/CYP3A4.
      One dose of any drug, including buprenorphine, leaves the body quickly– but taking a drug for days causes it to build up in the body, making tests positive far-longer. One dose is usually not detectable after 3 days, but someone who has taken it for months will test positive for a week or more after stopping.
      Finally, mass spectrometry will detect very low levels of a drug, whereas the initial screening, usually by immunoassay, is much less sensitive. Urine concentrates excreted substances, so dilute urine will have much lower amounts of the drug than concentrated urine- which also determines how long it will be detected.
      So even in one person, the time it can be detected will vary greatly. On the short end, with dilute urine and a one-time use, it will probably be gone on a couple days. In that same person but using regularly, without drinking as much water before the test, it could be present for 10 days.

  2. Hi, I am on Buprenorphin-Nalox 8-2mgs and I take my meds everyday & when I go to the doctor every month I take a drug test, well this month when I took my drug test my doctor told me that the meds did not show up in my system & I was dumbfounded because I take them everyday & I did not stop taking my meds, I didn’t do anything different. I do not understand why the meds I take everyday just like I’m suppost to didnt show up on the drug test I took and I didn’t do anything or change anything. Do u know what could of made this happen?? I have to go back in two weeks and if its not in my system my doctor will have to discharge me. This is so crazy because if I don’t take my meds I will be sick. I do not know what to do.

    • I understand the frustration. Doctors are taught in med school to ‘treat the patient, not the lab value’… but in these cases doctors do the opposite. Yes, patients with addictions often have secrets. But doctors should be extremely careful before taking actions with risk of significant harm to patients!

      Some possibilities… if you were very well hydrated, the buprenorphine in your urine may have been too dilute for the test to pick up. If you usually drink lots of water, drink less before your next test. Or, your sample could have been mislabeled or mishandled by the lab, causing your result to be confused with another patient. If this happens again, ask your doctor to do a blood test. If it is low in that test, ask the doctor to have you dose in front of the doctor and then repeat the blood test. Ask your doctor what you can do to prove you are telling the truth. There are ways for the doctor to figure out what is happening, and a good doctor will do those things, if there are any reasons to believe that the patient is telling the truth.

  3. Thank you for your responds! I am going to have to do some deep research to find out why this happened to me, because it is truly not right and not fair that I’m going through this when I have done nothing wrong. I did find out that this has happened to other people at their doctor’s appointments. well I’m going to dig deeper into this cause I have to know. If anybody has any feedback for me, let me know. Thank u From Julia

    • There are a couple reasons. Buprenorphine medications are very potent. It is almost impossible for someone tolerant to opioids to overdose on buprenorphine. But deaths are possible in someone who 1. has no history of opioid use, AND 2. takes a second respiratory depressant. So one reason to check a UA is to make sure the patient is truly using opioids.

      Another reason is to verify what the patient says in his/her history about use of other drugs. I’ve found over the years that many people with isolated opioid dependence do very well on buprenorphine. But the success rate is much lower in people who are also addicted to crack cocaine, methamphetamine, benzos, or alcohol. IF a person tests positive for those substances I would want to let the patient know my expectations– i.e. how long I’ll allow them to teat positive for that substance before discharging them.

      There may be other reasons; some doctors may have concerns if the patient tests positive for buprenorphine. I don’t hold that fact against new patients because I’ve had many patients who tried a period of ‘self-treatment’ before they were able to find a physician.

    • You have to take a drug test every month for afew reasons. The doctor needs to know what’s in your system also your doctor tests has to make sure the meds they your are getting are in your system and that your not taking anything else your not supposed to be taking.

  4. Thanks for your reply Jeffrey. ….I know I’m going to test positive to diazapam as I have been suffering alot lately with anxiety……I drink alot and no I have to stop everything when going on this drug….but I’m worried what the side affects are of the drug itself on its own

    • Shoot… I had an answer then accidentally deleted it! The side effects are all based on mu receptor effects, i.e. typical opioid effects. If you have a very high tolerance, you may have mild withdrawal for a few days (just a bit of fatigue and feeling down). If you have a very low tolerance you will feel a bit ‘narcotized’ for a day or two. But very quickly your tolerance will line up, and you’ll feel normal, save for some constipation (in some cases).

      Good luck!

  5. I have a question for someone. So my husband has been going to one of those pay to prescribe doctors for about 7 months. He is prescribed 2 8mg strips a day. Today his doctor said his levels are really low, about 60, when they should be 300 – 400 (I’m not really sure what he’s measuring). Here is the issue.. We cannot afford for us both to go to the clinic, so he’s been sharing with me. I’m assuming that’s why he’s low, but that’s a lot lower than he should be. If he has an average metabolism, if he takes 1 sub before bed and 1 sub in the morning (his appointment is usually around 11:30) will his levels be okay? I know what we’re doing is illegal, I get that. We’re already paying $80 every 2 weeks for the visit, and about 20 is gas to drive almost 2hrs away to get it. There is no way we can double that. We’re not selling, just cheating the $$ system.

    • I’m not comfortable advising you on this issue, but you’ll find some help at my forum from other readers. Try posting it at http://www.suboxforum.com .

      I will add a couple general comments. It takes a few days for blood levels of buprenorphine to stabilize, so any one-day dose change will not have a big impact. The doctor may also be testing metabolites, which take a few days to build up as well and show if the medication was taken for only a couple doses, vs for several days.

      I hear you on costs, and I realize that there is only so much money available for most working families. I charge less than what you are paying. But you describe costs of $160 per month, or about $2000 per year. Opioid dependence is a horrible, oft-fatal illness that destroys relationships, personal health, jobs and employability. People addicted to opioids often end up with felony convictions, and lawyers cost much more than what you’re paying for treatment. Some people end up with brain damage or lose their lives– and no price can be placed on those things.

      Treating illness with similar morbidity costs much, much more. Treating breast cancer, for example, easily runs over 100 thousand dollars. A heart attack and bypass surgery will also run over $100K. Disc disease leading to spinal fusion can cost even more. Treating opioid dependence with buprenorphine is truly an incredible bargain. Understand that you may find an in-network doctor for those other illnesses, but most people find that many of the charges are not covered by insurance, either because of deductibles or an out-of-network anesthesiologist or radiologist or radiation oncologist.

      And even compared to other opioid addiction treatments, your cost is not that high. I work part time in a methadone program that is covered by medicaid, but NOT by private insurers– so people with jobs pay over $500 per month, every month, per person. My own treatment was mandated by the board to be abstinence-based, and they chose the program. The first 3 months of treatment cost almost $90,000 out of pocket– luckily we owned a vacation cottage in Wisconsin to sell in order to pay. I then had to pay for therapy and drug tests, twice per week, for 6 years– another $700 per month for those 6 years. When I completed the six years I had maxed out a number of credit cards, and since I lost my career and did another residency it took 5 years to pay them off.

      The issue that many doctors find to be the most frustrating is that many people who complain that they can’t afford treatment also smoke cigarettes. I don’t know if you do, but smoking one pack per day costs more than what you are paying for treatment. I realize that everyone needs to have a ‘hobby’– but I gave up a cottage on the lake that my kids used to enjoy, in order to do the right thing… and so I don’t think it is too much to expect people to stop smoking to pay for addiction treatment. If that seems too hard, then the person doesn’t truly understand the reality of the problem being faced. Treatment with buprenorphine will easily have a greater impact on your life than anything else you will ever do. And if you lose it, the financial costs will only be much, much greater.

      I don’t mean to ‘shame’ you, but I do mean to open your eyes, and maybe persuade you. Do what is necessary to keep your buprenorphine doctor. It can really get nasty if that is lost.

      • There is a fairly big difference between you and I, I will never own a cottage. My husband and I both dropped out of highschool addicted to heroin. Our combined incomes are probably less than how much you paid for your cottage. You know the poverty line? We couldn’t reach it if I wasn’t standing on his head. Let’s break down my necessary expenses. So our combined monthly income is about $1100. We pay $350/month for rent, about $60 for gas and same for electric. We have about $200/month in drug related fines, another $120 in gas BC we drive an old shitty SUV to work. Speaking of work, we already never see each other, in order to avoid child care costs we work opposite shifts. After all that is said and done, we’re left with $280/month not spent on “necessities”. That doesn’t even add in the cost of raising 2 boys, one who goes through jeans and shoes like they’re going out of style. So, yes, my cost is a lot lower than that of a cancer patient. Its all relative tho, isn’t it? You’re not opening my eyes, as you seem to think. You are doing as you said you weren’t, shaming me. I would go to a clinic that accepts my Medicaid, however last I called I was on a 6 month waiting list. The threat of relapse seems too high to just wait. Anyhow, thanks for the info

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