Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department

Abstract

Background and Aims Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. Design This is a retrospective cross-sectional study. Setting This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. Participants This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. Measurements The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40–399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. Findings For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9–4.8) compared with 5.5 (5.1–6.0) among those with medium and 7.7 (6.8–8.7) among those with low fentanyl concentrations. Conclusions Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.