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Table 1.  Characteristics of Urine Drug Test Specimens Tested Between November 14, 2019, and July 10, 2020
Characteristics of Urine Drug Test Specimens Tested Between November 14, 2019, and July 10, 2020
Table 2.  Logistic Regression Analysis for Populations With Positive Test Results for Selected Drugs Before vs During the COVID-19 Pandemic
Logistic Regression Analysis for Populations With Positive Test Results for Selected Drugs Before vs During the COVID-19 Pandemic
1.
Substance Abuse and Mental Health Services Administration.  Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019.
2.
Panchal  N, Kamal  R, Orgera  K,  et al. The implications of COVID-19 for mental health and substance use. Accessed August 11, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
3.
Twillman  RK, Dawson  E, LaRue  L, Guevara  MG, Penn  W, Huskey  A.  Evaluation of trends of near-real-time urine drug test results for methamphetamine, cocaine, heroin, and fentanyl.   JAMA Netw Open. 2020;3(1):e1918514. doi:10.1001/jamanetworkopen.2019.18514PubMedGoogle Scholar
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    Research Letter
    September 18, 2020

    Analysis of Drug Test Results Before and After the US Declaration of a National Emergency Concerning the COVID-19 Outbreak

    Author Affiliations
    • 1Office of the Assistant Secretary for Health, Washington, DC
    • 2Millennium Health LLC, San Diego, California
    JAMA. 2020;324(16):1674-1677. doi:10.1001/jama.2020.17694

    The novel coronavirus disease 2019 (COVID-19) pandemic has exacerbated challenges for millions of adults with substance use disorders.1 New obstacles for obtaining treatment exist as do increasing stressors, including isolation, unemployment, and illness.2

    To better understand the pandemic’s effects on drug use among those with or at risk of substance use disorders, we examined a convenience sample of urine drug test results.

    Methods

    The study protocol was approved by the Aspire independent review board and included a waiver of consent for the use of deidentified data. We conducted a cross-sectional study of urine drug test results from patients diagnosed with or at risk of substance use disorders. The drug tests were ordered by health care professionals as part of a comprehensive treatment plan3 between November 14, 2019, and July 10, 2020.

    Each specimen was derived from a unique adult patient. The analysis used definitive test results performed by liquid chromatography tandem mass spectrometry for cocaine, fentanyl, heroin, and methamphetamine. The patients who were reported to have been prescribed cocaine, fentanyl, or methamphetamine were excluded. A random sampling of 75 000 specimens were selected for both the period before COVID-19 (November 14, 2019, to March 12, 2020) and the period during COVID-19 (March 13, 2020, to July 10, 2020). The periods were based on COVID-19 being declared a national emergency on March 13, 2020.

    A 2-sample proportion test was used to determine if significant changes occurred in the demographic characteristics provided by the ordering clinician during the 2 periods (Wilcoxon test was used for patient age). Logistic regression was performed to evaluate the association of collection time and location (US Census region) with drug detection using an interaction term. Sex, age, and clinician specialty were added as potentially confounding covariates.

    Adjusted odds ratios (ORs), Sidak-corrected 95% CIs, and Tukey-adjusted P values for each drug model were estimated. The adjusted ORs represent the drug detection odds for the population during COVID-19 compared with the population before COVID-19. R statistical software version 4.0.2 (R Project for Statistical Computing) was used for the data analysis. Statistical significance was set at P < .05 and all tests were 2-tailed.

    Results

    The total sample included urine drug test results for 150 000 patients. The patients tested for the selected drugs during the COVID-19 period were significantly younger vs the period before COVID-19 (median age, 46 years vs 49 years, respectively), were more often male (48.48% vs 46.06%), and were more likely from a substance use disorder treatment setting (30.84% vs 25.47%) (Table 1).

    Compared with the period before COVID-19, the proportion of specimens testing positive during the COVID-19 period increased from 3.59% to 4.76% for cocaine (adjusted OR, 1.19 [95% CI, 1.11-1.29]; P < .001), from 3.80% to 7.32% for fentanyl (adjusted OR, 1.67 [95% CI, 1.55-1.81]; P < .001), from 1.29% to 2.09% for heroin (adjusted OR, 1.33 [95% CI, 1.11-1.61]; P = .002), and from 5.89% to 8.16% for methamphetamine (adjusted OR, 1.23 [95% CI, 1.14-1.32]; P < .001; Table 2).

    All US Census regions except the South Atlantic and West North Central saw significant increases in the adjusted OR for at least 1 drug. No US Census region saw a significant decrease in the adjusted OR.

    Discussion

    This study demonstrated that urine drug test positivity in a population diagnosed with or at risk of substance use disorders increased significantly for illicit cocaine, fentanyl, heroin, and methamphetamine from the 4 months before the COVID-19 emergency declaration to the 4 months after the COVID-19 declaration.

    This study has limitations. Individuals included in the analysis may have had incomplete or inaccurate medication lists that could result in inclusion of some patients with a prescribed substance. The study used a convenience sample, and variation in patient characteristics occurred after the COVID-19 emergency declaration. Although sex, age, and clinician specialty are associated with illicit drug positivity, they were accounted for in the regression model.

    However, patients being tested during the pandemic may be at inherently higher risk and this self-selection could not be captured. Whether the increases reflect increases in new use or relapse are unknown. Differences in the pandemic or response at the state level could influence the results. The short time frame and dichotomized periods are limitations; fentanyl and methamphetamine use increased between 2012 and 2019 without an indication of seasonality.3

    Section Editor: Jody W. Zylke, MD, Deputy Editor.
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    Article Information

    Corresponding Author: Brett P. Giroir, MD, US Public Health Service, US Department of Health and Human Services, 200 Independence Ave SW, Washington, DC 20201 (ashmedia@hhs.gov).

    Accepted for Publication: August 27, 2020.

    Published Online: September 18, 2020. doi:10.1001/jama.2020.17694

    Author Contributions: Dr Giroir had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Wainwright, Mikre, Whitley, Huskey, Lukowiak, Giroir.

    Acquisition, analysis, or interpretation of data: Wainwright, Mikre, Whitley, Dawson, Giroir.

    Drafting of the manuscript: Wainwright, Mikre, Whitley, Dawson, Giroir.

    Critical revision of the manuscript for important intellectual content: Wainwright, Mikre, Whitley, Huskey, Lukowiak, Giroir.

    Statistical analysis: Whitley, Dawson.

    Administrative, technical, or material support: Mikre, Giroir.

    Supervision: Huskey, Lukowiak, Giroir.

    Conflict of Interest Disclosures: Mr Wainwright and Dr Giroir reported the US Department of Health and Human Services (DHHS) has a data donation agreement with Millennium Health to receive near real-time drug test data to enhance efforts and target approaches in fighting the overdose crisis in the US. This donation is an effort to improve the work of the DHHS with state and local officials on drug trends in their areas and to target coordination of preventive health care resources to avoid overdoses. Mr Whitley and Drs Dawson, Huskey, and Lukowiak reported being employees of Millennium Health LLC. No other disclosures were reported.

    Funding/Support: This study was supported by Millennium Health LLC.

    Role of the Funder/Sponsor: Millennium Health provided technical assistance on the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Substance Abuse and Mental Health Services Administration.  Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019.
    2.
    Panchal  N, Kamal  R, Orgera  K,  et al. The implications of COVID-19 for mental health and substance use. Accessed August 11, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
    3.
    Twillman  RK, Dawson  E, LaRue  L, Guevara  MG, Penn  W, Huskey  A.  Evaluation of trends of near-real-time urine drug test results for methamphetamine, cocaine, heroin, and fentanyl.   JAMA Netw Open. 2020;3(1):e1918514. doi:10.1001/jamanetworkopen.2019.18514PubMedGoogle Scholar
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