Urine Drug Testing has a storied history. Starting during the Vietnam era as a way to find and detox servicemen on drugs before their return to the US, drug testing began in an authoritative environment with a specific mission. From there it spread to transportation, safety sensitive positions and legal environments, and with this spread it ran into new challenges that had to be overcome. Several decades of legal action, compromise and technical achievements have led us to the present, but, like any evolutionary process, there are leftovers from the origin of drug testing that may still be hanging on with no current purpose. It’s time to take a new look at drug testing. Rather than there being one way to do drug testing, we should use what we know to construct specific programs for specific purposes. As I treat addiction, I’ll focus on drug testing in addiction.
What differentiates drug testing in addiction from, say, drug testing in workplace drug use, is the presence of an illness. In doing drug testing to monitor an illness such as addiction, one is not trying to “catch” someone doing something wrong. One is monitoring one aspect of the illness. So rather than providing a means to a legal deterrent, drug testing becomes a medical tool, and I prefer to use the term Medical Monitoring for Adherence (MMA), where adherence refers to adherence to the plan of care, which includes abstaining from using drugs or alcohol.
Since we’re talking about a medical situation, let me give you another one to compare with. Let’s say you have an infection. The doctor tells you to take 10 days of antibiotics and cautions you not to stop before the 10 days are up. The reason you should take the whole course of 10 days is that some bacteria are more easily killed by the antibiotic than others, and if you just take it until you feel better most, but not all, of the bacteria will be dead. The only ones left will be those most resistant to the antibiotic, and they’ll grow to create an even worse infection if left alive. Now imagine there was a test that would measure the number of bacteria in the body, and you could do it every day during the 10 day course. When that number reached zero you could safely stop the antibiotic. What that test would do is give us patient specific information rather than population specific information. What we have now is the latter. The same is true with Medical Monitoring for Adherence in addiction.
Now, understanding that we are not yet into patient specific indicators for MMA, let’s look at two programs based on population that have documented success rates. Surprisingly, these two programs have much higher success rates than those reported for the general population and are considered the “gold standard.” Since they are very different they should give us some sense of what the important factors are. The first program is that of Navy pilots and the second is that of physicians.
The high rate of treatment success in these programs have been criticized as not being applicable to other populations because of the high educational achievement of the participants and the fact that they all have professional licenses (to fly or practice medicine) that gives coercive power over them. In fact, the physician monitoring programs have been replicated in less well educated populations with no significant decrease in effectiveness. In addition, illness, when understood as illness, provides its own coercive force on behavior. So I think these are good programs to look at.
Both Navy pilots and physicians have a greater than 90% five-year success rate at achieving and maintaining abstinence from drugs and alcohol. Both have 5 year MMA programs. Both have random testing. Both have wide panels including indicators for alcohol. Both utilize a tapering frequency of testing over the years of participation. Both programs require other behavioral changes in addition to abstinence. Both are still based on population; that is, there is no measure when someone is ready to leave the program at three years or needs to stay seven.
One might be tempted to look cynically at these programs and say, “Sure they’re sober for five years, but you’re testing them for five years.” What happens in year six? There is some evidence to suggest just that, and some state physician health programs are looking at extending their contracts to longer than 5 year periods of monitoring. However, this “monitoring period” idea is one of those vestigial aspects that no longer makes sense. When drug testing began, there was no understanding of addiction as a chronic illness; it was seen as a habit that you just had to break long enough to stay away from. The period came from what was necessary for the vast majority to “break the habit.”
But if we see addiction as a chronic illness then there’s no habit to break. The symptoms that caused the drug use in the first place are there until treated. So does that mean that if we had a medical treatment for addiction we wouldn’t need the monitoring? No, because there are behavioral aspects and no treatment is perfect, but a combination of medical treatment, MMA, and other medical surveillance should give us a more personalized approach to the length of time MMA is needed.
So let’s construct the “perfect” MMA program for medical treatment of addiction. We’ll have to compromise because of cost in some places, and for other reasons in other places, but “perfect” gives us something to shoot at.
Frequency: Frequency should start out at twice a week (because the most common things tested for can be detected at 3 to 4 days) and should be random. Each day should be liable for testing so that the person doesn’t know what’s coming. It should be truly random so that two days or even three in a row are possible.
Matrix: The matrix is the substance tested (urine, hair, saliva, etc). Urine is the perfect matrix for MMA as its collection is non invasive, it can be tested frequently with changes in state (unlike hair which doesn’t change much over time), and increases the time of detection (saliva can only detect what is there at present). There are some challenges to using urine: certain medical conditions, the fact that urine is chemically “dirty” because its a waste product, and others. Technology and modern lab techniques can overcome all of these challenges.
Test Panel: It should be very wide and constantly changing as new drugs become problems. The original drug test called the “DOT 5″ included THC, PCP, Benzodiazepines, Cocaine, and Barbituates. Developed when PCP was a growing problem, it made sense. Today PCP is something rarely used by itself, but most testing programs can’t stop looking for it because of it’s place in the canon of federal testing. Meanwhile, synthetic cannabinoids, a growing problem today, are not in most panels because they don’t change fast enough. As long as users have access to new drugs for significant periods before they are looked for, MMA will be limited in its effectiveness.
Testing Method: Some screening method to include screening for adulterants followed by Mass Spectrometry (MS) confirmation with quantification and normalization to individual hydration level with medical interpretation is the gold standard. Let’s take each of those factors in turn. “Screening followed by confirmation” – It may soon be possible to test for everything via confirmation testing but it is still more expensive and so we use screening techniques to find those samples most likely to be positive. The screening technique chosen should be overly sensitive so that positives aren’t missed. The confirmation gold standard is some kind of chromatography (liquid or gas) followed by MS which allows for the quantification of the various metabolites present. “Adulteration testing” – as long as there is MMA there will be those who try to defeat it by various methods. All screening should include screening for adulteration and dilution of urine in attempts to avoid monitoring. “Normalization” – in serial testing early in treatment or following a relapse into drug using behavior a dichotomous result becomes unimportant. It is necessary to do serial measurements to follow the falling level of metabolites in order to determine that drug using has stopped. This leads to the problem of nominal levels that rise because of concentration of the urine due to dehydration. Techniques have been developed to create normalized values to do serial comparisons. “Medical Interpretation” – MMA is a medical procedure and while other entities (courts, probation officers, employers, etc) have taken it on, it remains something best interpreted with the individual’s medical condition in mind. That is why federally regulated programs include a Medical Review Officer (MRO) and why all programs using MMA should have a physician interpret the results. Given the complexity of metabolic pathways, normalization coefficients, and interpretation algorithms, it is not likely that the layman can accurately interpret MMA results.
So now we have the “perfect” MMA scheme: daily randomization of twice weekly testing the first year, followed by two years of weekly testing, a year of monthly testing and a year of testing every two months. The panel should include: ETG/ETS (ethanol metabolites); THC; synthetic cannabinoids; amphetamine; methamphetamine (with the ability to test for d and l forms); cocaine; the substituted cathiones (bath salts); a list of benzos too long to list here; barbituates; opioids and opiates including buprenorphine, methadone, and oxycodone; the “Z-drugs”; and what ever addiction medication the person is taking. The confirmed, quantified, normalized results should be back in the office the next day with medical interpretation to allow for fast intervention.
Now back to reality. No one is going to go for more than once a week testing unless they are in intensive treatment. The most you’re going to get out of outpatients after treatment is weekly, and a true randomization scheme will aid in mitigating the decreased frequency. Some will say they can’t test weekly for the first year, and that may be so, but less frequent testing has not been shown to provide the behavioral fence around the illness that at least weekly testing has.
Some programs will say they can’t afford confirmatory quantified testing. They will always wonder if that positive was really positive, and when someone’s job or freedom is on the line, using non confirmed tests opens one up to considerable liability. Even in a pure treatment setting with no forensic implications, a non-confirmed test will open the program to losing the patient’s confidence by acting on a false positive. Some will say they need no medical interpretation, but they will also open themselves up to liability in interpreting the results if they get it wrong.
Labs focused on work place testing or pain clinic testing just don’t have the same focus or understanding what what an addiction treater needs in a lab. Personally, it’s taken me a long time to find a laboratory that is focused on helping those who treat addiction and need MMA. It’s taken a long time to find a lab that will pick up our samples and get the confirmed, quantified, interpreted results back to us quickly. The more people who treat addiction focus on what we need from a lab rather than settle for what the lab wants to give us the more prevalent will be the labs that can really help us treat patients.
© Howard C Wetsman MD FASAM