Furosemide as a potential unintended urine drug screen confounder during methadone maintenance treatment

Rachel L. Bauer, PharmD; Wesley L. Geminn, PharmD; Jason A. Carter, PharmD

doi:10.5055/jom.2015.0295

Authors

Rachel L. Bauer, PharmD
Wesley L. Geminn, PharmD
Jason A. Carter, PharmD

DOI:

https://doi.org/10.5055/jom.2015.0295

Keywords:

furosemide, methadone, urine drug screen, addiction, monitoring, opioid, urine creatinine, diuretic

Abstract

Patients receiving chronic methadone maintenance treatment (MMT) for addiction are closely monitored for signs of relapse. Urine drug screen (UDS) comprises a major component of ongoing patient assessment. As patients continue with MMT, developing medical conditions may necessitate addition of medications that interfere with UDS. Although widely accepted as masking agents, little guidance is available regarding management of patients receiving MMT with legitimate medical need for diuretics. The following describes a case in which furosemide clinically interfered with UDS interpretation for a patient receiving MMT. Potential management strategies are also discussed.

Author Biographies

Rachel L. Bauer, PharmD

Resident Pharmacist, Department of Clinical Pharmacy, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee; Tennessee Department of Mental Health and Substance Abuse Services, Division of Clinical Leadership, Nashville, Tennessee

Wesley L. Geminn, PharmD

Chief Pharmacist and State Opioid Treatment Authority, Tennessee Department of Mental Health and Substance Abuse Services, Division of Clinical Leadership, Nashville, Tennessee.

Jason A. Carter, PharmD

Associate Professor, Department of Clinical Pharmacy, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee; Chief Pharmacist and State Opioid Treatment Authority, Tennessee Department of Mental Health and Substance Abuse Services, Division of Clinical Leadership, Nashville, Tennessee

References

United States Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: N-SSATS Report: Trends in the Use of Methadone and Buprenorphine at Substance Abuse Facilities: 2003 to 2011. Rockville, MD, 2013.

McCance-Katz EF, Sullivan LE, Nallani S: Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: A review. Am J Addict. 2009; 19: 4-16.

Flockhart DA: Drug interactions: Cytochrome P450 drug interaction table. Indiana University School of Medicine Web site. 2007. Available at http://medicine.iupui.edu/clinpharm/ddis/clinical-table/. Accessed March 2, 2015.

United States Substance Abuse and Mental Health Services Administration: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD, 2005: 63-58, 143-159. Treatment Improvement Protocol 43 (TIP 43).

Barr DB, Wilder LC, Caudill SP, et al.: Urinary creatinine concentrations in the U.S. population: Implications for urinary biologic monitoring measurements. Environ Health Perspect. 2005; 113(2): 119-200.

Redwood Toxicology Laboratory: Urine Creatinine. Available at https://www.redwoodtoxicology.com/docs/resources/creatinine_interpretation.pdf. Accessed January 11, 2015.

United States Department of Health and Human Services: Mandatory guidelines for federal workplace drug testing programs. Fed Regist. 2004; 69(71): 19644-19673.

World Anti-Doping Agency: World Anti-Doping Code: The prohibited list 2015, international standard. Available at https://www.wada-ama.org/en/resources/the-code/world-anti-dopingcode. Accessed March 1, 2015.

Jaffee WB, Trucco E, Levy S, et al.: Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing. J Subst Abuse Treat. 2007; 33: 33-42.

Cadwallader AB, de la Torra X, Tieri A, et al.: The abuse of diuretics as performance-enhancing drugs and masking agents in sports doping: Pharmacology, toxicology, and analysis. Br J Pharmacol. 2010; 161: 1-16.

Yonkers KA, Howell HB, Gotman N, et al.: Self-report of illicit substance use versus urine toxicology results from at-risk pregnant women. J Subst Use. 2011; 16(5): 372-389.

Zanis DA, McLellan AT, Randall M: Can you trust patient self-reports of drug use during treatment? Drug Alcohol Depend. 1994; 35(2): 127-132.

United States Substance Abuse and Mental Health Services Administration: Clinical Drug Testing in Primary Care. Rockville, MD, 2012: 31-50. Technical Assistance Publication Series 32 (TAP 32).

Cone EJ, Caplan YH, Moser F, et al.: Normalization of urinary drug concentrations with specific gravity and creatinine. J Anal Toxicol. 2009; 33: 1-7.

Larson MEM, Richards TM: Quantification of a methadone metabolite (EDDP) in urine: Assessment of compliance. Clin Med Res. 2009; 7(4): 134-141.

Murphy JL, Hurt TL, Griswold WR, et al.: Interference with creatinine concentration measurement by high dose furosemide infusion. Crit Care Med. 1989; 17(9): 889-890.

Saibaba KSS, Vijaya Bkaskar M, Srinivasa Rao PVLN, et al.: Interferences in clinical chemistry analysis. Indian J Clin Biochem. 1998; 13(2): 55-62.

Furosemide [package insert]. Bridgewater, NJ: Sanofi-Aventis US LLC, 2012.

Chermack ST, Roll J, Reilly M, et al.: Comparison of patient self-reports and urinalysis results obtained under naturalistic methadone treatment conditions. Drug Alcohol Depend. 2000; 59: 43-49.

Sherman MF, Bigelow GE: Validity of patients’ self-reported drug use as a function of treatment status. Drug Alcohol Depend. 1992; 30(1): 1-11.

United States Substance Abuse and Mental Health Services Administration: Data Summary: Methadone Mortality: A 2010 Reassessment. Paper presented at Methadone Mortality: A 2010 Reassessment Meeting, Washington, DC, July 29-30, 2010.

Preston KL, Epstein DH, Davoudzadeh D, et al.: Methadone and methadone metabolite urine concentrations in patients maintained on methadone. J Anal Toxicol. 2003; 27: 332-341.