Drug testing carries the connotation as a punitive course of action associated with harsh consequences. In truth, drug testing (which includes alcohol testing) is a highly compassionate and therapeutic modality associated with improved treatment adherence, less relapse and the best chance to rebuild trust with family members, loved ones, employers and regulatory organizations.
My addiction had taken everything that I loved away from me. My marriage, the opportunity to see my kids, my career as a physician, my freedom, my respite in the mountains, nearly a million dollars in cash and stuff I owned. After 8 months in treatment, I realized that a choice had to be made. I could either keep using drugs and drinking, or rebuild my marriage, see my kids and resume my career. Until that day, I always believed I could have both. After all, I was a very smart doctor. Even after losing everything I loved, that belief, or denial, or whatever you want to call it, persisted and I was making plans on how I’d do it different this time and not get caught. But then my kids came to visit. I hadn’t seen them in 4 months. They asked when I was coming home for good this time. That question shook my soul. My first thought was I’ll never come home for good, because I am an addict. I wept.
Five years later…I am the associate medical director at a top addiction treatment program within an academic medical center with the rank of Associate Professor of Medicine. Each day I call to see if I need to provide a sample for a drug test.
The truth is, in spite of everything I have lost, and all that I know about this disease, if it were not for having to make that call each day, I would use again. Not because I am stupid, or unaware of the consequences for me, my family and career but simply because a small part of me still wants to get high—because I am an addict—and making that call each day saves my life.
–T. Scott, MD
Dr. Scott’s experience takes us beyond the hard science of toxicology, toward a better and perhaps a seminal understanding of both the importance of testing and the severity of this disease. After all, the trust has been lost, words and convoluted explanations of behavior no longer matter to those who have lost trust and hope. But a simple drug test can establish the presence or absence of a drug better than anything else we know of. Over time, trust can be regained and relationships once broken can heal.
Drug Testing: The Current Dilemma
To date, no universal standard exists for clinical application of drug testing for monitoring addicts, diagnosis, medication monitoring, or continuous care. The American Society of Addiction Medicine (ASAM) has rightfully identified that the absence standards, has left a gaping hole in clinical practice, with both legal and professional ramifications. Until recently, ASAM’s policy regarding drug testing is that decision and process be determined by the provider based on the patient’s individual needs and circumstances, rejecting arbitrary protocols and rules imposed by 3rd party payers. As a result, ASAM and others have begun to investigate and provide both the rationale and appropriateness of drug testing in order to guide clinical decisions and improve the quality of care for patients with substance use disorder.
Recently (May/June 2016), The RAND Corporation at UCLA convened an expert panel to review the best available scientific evidence with the experience of noted experts in addiction medicine regarding the appropriate clinical practices’ needs and identify areas where research is needed.
The recommendations included:
- Drug test results should not be used as the sole determinant in assessment for substance use disorder. They should always be combined with patient history, psychosocial assessment and a physical exam.
- If drug testing results contradict self-reports of use, therapeutic discussions should take place.
- Providers should present drug testing to patients as a way of providing motivation and reinforcement for abstinence.
- Providers should educate patients as to the therapeutic purpose of drug testing.
- To the extent possible, persuade patients that drug testing is therapeutic rather than punitive to avoid an ‘‘us versus them’’ mentality.
- Treatment providers should include drug testing at intake to assist in a patient’s initial assessment and treatment planning.
- Results of a medical and psychosocial assessment should guide the process of choosing the type of drug test and matrix to use for assessment purposes.
- Drug test results should not be used as the sole determinant in assessment for substance use disorder. They should always be combined with patient history, psychosocial assessment, and a physical examination.
- Drug testing may be used to help determine optimal placement in a level of care.
- Drug testing can serve as an objective means of verifying a patient’s substance use history.
- Drug testing can demonstrate a discrepancy between a patient’s self-report of substance use and the substances detected in testing.
- For a patient presenting with altered mental status, a negative drug test result may support differentiation between intoxication and/or presence of an underlying psychiatric and/or medical condition that should be addressed in treatment planning.
- Drug testing can be helpful if a provider is required to document a patient’s response to treatment-current substance use.
Why Does This Matter?
Drug testing is the gold standard for outcome studies as tests do not lie or minimize use. Tests clearly can determine the presence of drug in an individual. When a famous person like Prince or Whitney Houston or others die, we all know that a forensic pathologist will find out the drugs that they have taken. It is a science and they are great at getting these answers.
Monitoring progress, relapse and treatment adherence are essential components of optimal treatment. For physician treatment, a change in urine test results can mean that a physician is removed from practice and enters a rehab. Five years of clean urine may mean that a physician is released from follow-up by the Board of Medicine.
At present, monitoring is underutilized in Internal and Family Medicine, Ob/Gyn, Psychiatry and really most every specialty other than Addiction Medicine. Important clinical encounters and diagnoses would change if, pediatricians, internists, OBs, family medicine, emergency room physicians, psychologists, and psychiatrists used drug testing. Certainly, the police will tell you that they know who is driving erratically but they do not know until they test who is driving under the influence of alcohol or drugs. Drug testing can assist in finding people under the influence, in the diagnosis of substance use disorder and in relapse prevention. When used in the hand of trained professionals, the treatment outcomes are enhanced.