When speaking with substance use disorder (SUD) counselors, the topic of drug testing often elicits mixed reactions. On one hand, counselors may sometimes view it when used by others as punitive (e.g., concluding an employment application process; termination of employment as a result of a positive UDS; violation of conditions of probation or parole). On the other hand, it may be viewed as a therapeutic tool used to help people achieve recovery from addiction or in pain management (Jarvis et al., 2017).
Effectively Utilizing Drug Tests
Drug testing can provide clinicians with an important tool. Part of the initial assessment of patients being evaluated involve discussions of different drugs used, for needs for detoxification and to assess for a diagnosis of opioid use as in methadone clinics.
Addiction treatment providers should utilize drug testing “to explore denial, motivation, and actual substance use behaviors” with patients (ASAM, 2017). If drug testing results contradict self-reports of use, this provides the opportunity for therapeutic discussions to take place. Providers should present drug testing to patients as a way of providing motivation and reinforcement for abstinence and should educate patients as to the value of drug testing to them. To the extent possible, persuade patients that drug testing is therapeutic, rather than punitive to avoid an “us versus them” mentality. If patients refuse a drug test, the refusal itself should be an area of focus in their treatment plan (ASAM, 2017).
Drug testing can be done in a number of different ways, including urine drug screening (UDS), which is the most common but the most prone to sample tampering through “dilution, substitution or adulteration” (ASAM, 2017). There is also blood or saliva testing, or even breathalyzer tests, historically used for alcohol only, but “police might soon be able to detect more than just alcohol on their breathing test devices. A new Swedish-designed device can detect twelve different controlled substances, including methamphetamine, cocaine, heroin, morphine, and marijuana” (Koebler, 2013; Beck, Stephanson, Sandqvist, & Franck, 2013). Some testing methods are more invasive than others. For most substances including alcohol, the window of detection is usually short. One exception is the testing of hair, which can identify drug use in up to the last three months. However, a drawback is that it will not detect the substance for a least seven days after use occurs, as the hair has to have the opportunity to grow. In addition, heavily chemically treated hair is not appropriate for drug testing (Beck et al., 2013).
One area where the differing views is most apparent is in situations of criminal justice referrals to addiction treatment. The conflict is easily explainable: for the criminal justice system, the desired outcome is public safety, while for clinician, it is recovery. This seeming conflict is resolvable when considering that a positive outcome to a SUD is likely to reduce or eliminate the criminal behavior.
The Value of Drug Testing
To be the master of the obvious, “alcoholics drink” and “drug addicts use drugs,” and while this does occur, it does not make use acceptable during treatment. When viewed as a therapeutic tool, drug testing informs us about patient progress. When patients use during treatment, the message is that this is something inconsistent with their treatment progress and the response should be—I say this because there are treatment programs whose immediate response is administrative discharge—to revisit and revise the treatment plan. How do these administrative discharges for illicit use differ from discharging patients being treated for COPD for coughing, or discharging those who are being treated for psychosis for hallucinating? However, should substance use continue to occur during treatment, it is incumbent on clinicians to ask themselves whether patients are receiving the needed clinical services and/or the clinically appropriate level of care. Also, in terms of language we need to replace the terms for UDS results of “clean” or “dirty” with “positive” and “negative” to reduce stigma.
The value of UDS as a treatment tool may be best illustrated by the success of physician health programs (PHP). In these programs, and in treatment in general, UDS works best when it is random. The use of UDS and/or breathalyzers is even more important in outpatient treatment or residential treatment services in which individuals spend time outside of the residence for part of the day (e.g., halfway houses). Explaining the rationale for drug testing to patients provides us with the opportunity to describe the power of addiction. Testing for illicit or nonprescribed substances not only measures patients’ progress, but for many patients the threat of discovery adds to their motivation to remain abstinent.
What Should We Test For?
UDS comes in different panels—for the number of different drugs or drug classes assessed—and generally, more is better, but also more expensive and may have to be balanced by cost considerations. I once hired a physician as my program’s medical director—oddly a heroin addict, and odd because of physicians’ access to legal narcotics—who had successfully completed a five-year PHP in another state. When he came to us, he volunteered to enter our state’s PHP and continue to be subject to random drug screening. After a while, the nurses began noting that when he was contacted in the middle of the night about patient issues, he seemed drug-affected, even though his UDS was always negative. What we eventually learned was that he was drinking heavily overnight, and because his drug of choice was heroin, the program never tested him for alcohol use.
According to ASAM, “As a general principle, drug testing should be scheduled more frequently at the beginning of treatment. . . . As the patient becomes more stable in recovery, the frequency of drug testing should be decreased, but performed at least on a monthly basis. Individual consideration may be given for less frequent testing if a patient is in stable recovery (ASAM, 2017).
UDS Abuse and Other Concerns
Some programs abused UDS by testing every patient, every day, and billing insurance for the procedures. These programs were generating more revenue from the drug testing than from the treatment there were providing. The National Health Care Anti-Fraud Association (NHCAA) indicates that the majority of health care fraud is committed by a small minority of dishonest health care providers. Fraudulent providers take advantage of the confidence entrusted to them by their patients. The actions of these providers destroy the reputation of perhaps the most trusted and respected programs and physicians in our society.
For example,
The audit on MassHealth [the Medicaid Program in Massachusetts] generated the following findings: MassHealth paid for drug tests allocated to members on a daily basis for extended periods, sometimes surpassing a year. This process deviated from the guidelines recommended by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), and those of other substance abuse treatment professionals. It was found that MassHealth could have saved approximately $7.8 million if the state’s policies and procedures were adhered to (Walton, 2015).
Medicare wants to reduce the frequent use of confirmation tests by labs that charge for follow-up tests when initial tests show no sign of an illegal substance. Medicare says that some confirmation tests are not medically necessary and inflate charges for taxpayers who support Medicare.
Other issues can be associated with drug testing. An inpatient addiction treatment program which both drug tested its patients and did random searches had a policy that if patients were found to be “holding” (i.e., in possession of illicit drugs), those people were discharged on the first offense. However, the policy stipulated that patients could have two positive UDS results before being administratively discharged. When the news went throughout the facility that a search was in process, patients who had drugs in their possession but had not previously had a positive UDS result, used the drugs they had. There may be a message in this about unintended consequences of certain policies.
Here is another dilemma. The DSM-5 states that remission requires that patients meet none of the eleven diagnostic criteria for a SUD for a year with the possible exception of craving (APA, 2013). The DSM-5 further maintains that there are three different severities of the disorder: mild, moderate, and severe. While it is clear that those with a severe SUD are addicted (compulsion, loss of control, continued use in spite of adverse consequences and craving), we cannot consider those in the mild category as addicted (abuse in the DSM-4). These folks may be in an environment which fosters abusive use (e.g., college or the military) and after leaving that environment, continued problematic use, enough to be diagnosable, stops. There are also those individuals who often resort to the use of substances to cope with difficult or overwhelming situations. However, if they develop the necessary coping skills and/or the situation changes for the better, they may continue to use without problems but still have positive breathalyzer or UDS results if tested. What is the clinically appropriate response to individuals who have a positive breathalyzer or UDS who have been previously diagnosed with some SUD of mild severity?
References
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author.
American Society of Addiction Medicine (ASAM). (2017). Appropriate use of drug testing in clinical addiction medicine. Retrieved from https://www.asam.org/docs/default-source/quality-science/2017_4_5_appropriate-use-of-drug-testing-in-clinical-addiction-medicine-document.pdf
Beck, O., Stephanson, N., Sandqvist, S., & Franck, J. (2013). Detection of drugs of abuse in exhaled breath using a device for rapid collection: Comparison with plasma, urine and self-reporting in forty-seven drug users. Journal of Breath Research, 7(2), doi: 10.1088/1752-7155/7/2/026006
Jarvis, M., Williams, J., Hurford, M., Lindsay, D., Lincoln, P., Giles, L., . . . Safarian, T. (2017). Appropriate use of drug testing in clinical addiction medicine. Journal of Addiction Medicine, 11(3), 163–73.
Koebler, J. (2013). New breathalyzer can detect marijuana, cocaine, heroin. Retrieved from https://www.usnews.com/news/articles/2013/04/25/new-breathalyzer-can-detect-marijuana-cocaine-heroin
Walton, A. (2015). Counteracting fraud, waste, and abuse in drug test billing. Retrieved from http://digitalcommons.lasalle.edu/cgi/viewcontent.cgi?article=1008&context=ecf_capstones
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