If you see addiction as an illness, and you want a monitoring system in place to make sure that the illness is contained as part of a larger treatment program, you probably want better drug testing than you have.
There are several questions to ask:
1. How often to test
2. What to test for
3. What method to use for screening
4. When to confirm and what to confirm for
But there is a larger question that underlies all of these and is the reason that any testing is done at all. That question is, “Has the patient used any substances since the last test?” We want to know if the patient is abstinent, if the usage, and that part of the illness, has been contained. We want to know that because there are certain parts of treatment that are appropriate for someone who is abstinent that are a waste of time if they aren’t. And there are certain interventions that are important if someone isn’t abstinent that are not only a waste of time, but actually hurtful, if the patient is.
So we really don’t want to know positive or negative answers unless they answer the larger question. A positive on a point of care (POC) cup for THC isn’t important unless it answers the question of whether or not the patient used since last tested. I’ve never seen a lab that actually caters to treaters of addiction in order to be able to give us a fast, accurate, reasoned answer to the big question. And when you think about it, it’s not a question a lab is designed to answer.
They want to answer the little questions, “Did he have more than 50ng of THC per ml in the sample you put in the cup?” or “How many ng of THC per ml was in the sample you sent?” A lab is a technical place and they want to answer technical questions. But clinicians don’t treat test tubes and we want answers that are important to the treatment we’re doing.
In a perfect world, we would test everyone everyday with a perfect confirmation analyzer we had in the clinic and get immediate and perfectly accurate results immediately. Oh, and it would be free also. So much for a perfect world.
So what we have now is a set of compromises because of the inability to get to that perfect goal and we come up with different compromises based on our setting (clinic, doctor’s office, inpatient, forensic, etc), the cost, our need for accuracy, our or our patients’ ability to pay, and our ability to wait. So before we can answer those four questions above we need to know these important factors.
I’ll give you my factors, but they are just mine. Yours will be different if you work in a different setting. My patients largely have insurance so can pay for testing. They are in an Intensive Outpatient Program (IOP) so they are seen frequently. They have jobs and resources so that they can afford drugs and have the freedom to go get them in between sessions if the disease is not contained. They may be on medications that need to be monitored to be sure the patient is taking them correctly. We track our patients’ progress through treatment with a numerical system so that we know what intervention to do when, so it’s important for us to know on a daily basis that the disease is contained or not; therefore we need the answers fast. Our goal is to prevent more expensive inpatient admissions so, some added cost for drug testing is acceptable. We need accurate answers on not only drug levels but corrected drug levels for state of hydration so that we can see if someone’s level is falling or rising.
So here’s what we’ve come up with. Because we need answers fast we use POC testing for as many things as we can. It’s not very accurate so we have to confirm our positive results. The problem is that the negatives aren’t always accurate either (especially for methadone, opiates, and benzos) so if we’re suspicious we have to send the entire panel off for confirmation. We’d love to confirm every test everyday, but can’t because of cost so we only do negatives when we’re suspicious. We test three times a week at first, though we’d like to test everyday but the cost is prohibitive, and lower to twice a week and then weekly as the patient stabilizes. If there is a positive we go back to three times a week and taper according to the person’s stability. We confirm our POC testing for the entire panel one time at first (to ensure that negatives are really negatives before using POC routinely) and then for suspicion, because we’ve had cases where people have been using something that POC testing can’t test for (like Z drugs or Soma). If on first test we find something like that we follow with lowest level of testing available to monitor for that. When we send things to the lab we always get validity testing to measure an accurate creatinine. That’s for comparing inter-test levels of drugs. For instance if we test someone a second time and the level went up, does it mean they used or are dehydrated the second time? With creatinine corrected values we can tell.
What I want is to find a lab that will come and pick up my samples after group and drive them overnight to the lab so that they can be tested first thing in the AM. I want the answer to the question before I see the patient again the next day. Otherwise I won’t be able to do the best intervention the next day. I want the lab to do the testing with accurate measures so we don’t need to keep confirming negatives and only confirm positives. I want that right away as well. This is going to cost, but it will save in other ways. Because I get the answer fast, treatment will go better and faster. I understand that in other treatment programs that say the same thing to each person everyday, it doesn’t matter, but to us it does. If I don’t have to use POC for fast results I can skip that step and use more accurate screening with the lab’s machine, thereby saving the necessity for confirming negatives. And when I get the answer from the lab, I want the answer to my question, not the answer to theirs.
Will I get that? Maybe one day. There’s a big shake up in our space because of parity, a new biological view of addiction, a more medically managed approach. We probably need to start from the bottom up because most labs available to us now started as monitors for pain management programs. Insurance companies have to start seeing their whole cost of the illness rather than looking only at treatment. Society has to embrace this illness as an illness rather than something blameworthy so the emphasis can leave “catching” and go to monitoring. We’ll need better informatics so that we can take advantage of the improved information flow and it will result in better treatment. I think we have a better treatment program, but currently our drug testing is holding us back. Others are probably holding back from improving treatment because the drug testing to support it isn’t available. Hopefully, that will change soon.
© Howard C Wetsman MD FASAM