Public Policy Statement On Drug Testing as a Component of
Addiction Treatment and Monitoring Programs and in other Clinical Settings
[Note: ASAM also has a Public Policy Statement addressing “Drug Testing in Workplace Settings”]
The collection and analysis of body fluids, especially urine samples, for the detection of alcohol, nicotine, other drugs, or their metabolites, is a common feature of many addiction treatment services. The chemical compounds that act on reward pathways in the brain can be taken into the body by various routes. Because of their water-solubility and lipid-solubility, alcohol and other drugs are rapidly distributed to virtually every tissue in the body, and can be detected in these tissues for hours to even days after drug use. Saliva samples and hair samples have been used for the detection of such substances, and other body fluids or tissues may be used in the future in efforts to detect the presence of certain substances. In some instances, effective medical treatment cannot proceed without laboratory testing of this type. In this Policy Statement, the rationale for and uses of such testing are described, and for simplicity’s sake, the term ‘drug testing’ is used as a general term for such testing of urine or other body fluids or tissues. The presence of alcohol, nicotine, other drugs, or their metabolites in a patient’s body fluids or tissues can provide evidence of substance use; but it must be emphasized that evidence of substance use alone is insufficient to substantiate that a case of addiction is present, and similarly insufficient to substantiate that any functional impairment related to substance use is present. Drug testing can be a key component of the initial assessment process for a patient being evaluated for a possible diagnosis of substance-related disorder. When physicians conduct diagnostic examinations to rule in/rule out a substance use disorder, the use of drug testing can be just as essential a component of the diagnostic process as are the laboratory and radiographic evaluations that are components of diagnostic assessments for metabolic disorders. Drug testing is also an important diagnostic procedure in the assessment of psychiatric conditions, in which aberrant behavior, perceptions, thought processes, or affective states could be attributable to either a primary psychiatric condition or to the effects of a psychoactive substance.
Drug testing can be a component of the plan of care during treatment for a substance-related disorder. It is a common feature of treatment services for impaired health care professionals or others in other high-risk occupations, such as workers in the transportation and nuclear power industries. Parties other than the treating physician, such as state medical licensing boards and hospital medical staff credentials committees, may have an interest in the substance use status of the health care professional receiving treatment for a substance-related disorder, and thus may request authorization to receive results of drug testing conducted during addiction treatment.
Drug testing is also a feature of programs designed to provide ongoing monitoring of the health status of individuals who are no longer in an active phase of addiction treatment. It is not unusual for health care professionals such as physicians, who have been in an active state of addiction in the past and who are presumed in remission currently, to have the status of their condition monitored (albeit indirectly) by periodically, often randomly, ordered drug testing. In monitoring programs, the confirmed presence of substances from analysis of the urine, while not in itself diagnostic of a reactivation of disease, may help determine whether or not the monitored individual is, in fact, still abstinent.
The American Society of Addiction Medicine recognizes that the high prevalence of unrecognized substance use disorders represents a major public health problem that requires evidenced-based interventions. Arbitrary restrictions on drug testing jeopardize these efforts and create a barrier to engaging patients into cost effective and beneficial treatment.
In cases of stupor and coma, in which the differential diagnosis includes overdose of a substance--whether or not that substance has been prescribed by a physician or other health care provider--the collection of samples of urine, blood, or other body fluids is best termed “toxicology testing” and not drug testing.
In cases in which a controlled substance has been legally prescribed for the treatment of a medical condition, the collection of urine, blood, or other body fluids to detect the qualitative or quantitative presence of that agent is best termed “therapeutic drug monitoring” and not urine drug testing.
Addiction treatment is professional health care service that addresses a diagnosed substance use disorder, which is producing or has recently produced active symptoms or functional impairment.
Monitoring is the ongoing assessment of clinical status in an individual whose substance use disorder is in a state of remission (i.e., there are no current active symptoms and functional level is not known to be currently impaired).
It is the policy of ASAM that:
- Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and in monitoring of the ongoing status of a person who has been treated for addiction. As such, it is a part of medical care, and should not face undue restrictions.
- Urine drug testing, compounds tested for, and the composition of testing panels ordered by the physician, should be determined by the ordering physician to deliver quality patient care based on the unique clinical presentation of the patient.
- Arbitrary limits on reimbursements and restrictions on the number of tests; number of analytes; panel composition and type; frequency of testing; or methodology of testing interfere with the physician’s judgment and represent a discriminatory action prohibited by federal mental health and addiction parity legislation, which states that any limitations on addiction care may not be substantially different from limitations in any other area of health care.
ASAM recommends the following practices and procedures for drug testing:
A. The use of drug testing in diagnostic settings.
When patients are initially assessed to determine if there is a diagnosis of a substance-related disorder, it is essential for the health care professional to have objective evidence about the recent substance use status of the patient. Drug testing can provide evidence of current or recent exposure to intoxicants which could affect the patient’s current status, and can serve as an objective means of verifying the patient’s substance use history as reported by the patient or collaterals. ASAM recommends the use of drug testing where medically appropriate in clinical diagnostic settings.
A patient receiving inpatient or outpatient consultation to assess for the presence or absence of a diagnosable substance related disorder may refuse to provide a sample for urine drug testing, but an assessment without such data can be considered incomplete. The consultant in such circumstances may refuse to refer the patient for addiction treatment unless the patient provides a body fluid or other sample for a drug test.
In clinical settings where the patient’s level of arousal or behavioral activity is markedly aberrant, it is appropriate to collect urine for diagnostic purposes in order to assist in the differential diagnosis and in the development of the plan for indicated emergency medical care.
In clinical settings where trauma is being evaluated and managed, toxicology testing may be an essential component in the diagnostic process and to assist in planning emergency medical and surgical care. Additionally, serum ethanol assays can be very useful in the trauma setting to assist in case-identification and diagnosis of alcohol dependence, so that the post-emergency care plan can incorporate addiction treatment if indicated.
Serum assays, rather than urine assays for ethanol, are more useful for such purposes. In medical settings in which a plan of care has already commenced, an unexpected change in the patient’s level of arousal or behavioral activity can also warrant urine drug testing to detect the possible presence of intoxicants and thus to clarify the diagnosis.
B. The use of drug testing in addiction treatment settings.
Drug testing is appropriate during inpatient or outpatient addiction treatment, and is particularly appropriate at the onset of a course of treatment. Drug testing can be an effective therapeutic tool to assist in contingency contracting or other behavioral therapies. It can also serve as a deterrent to substance use and increase the likelihood of successful abstinence, especially if specimens are collected at random intervals. Periodic drug testing can be a part of a clinical protocol or practice guideline in some addiction treatment services. ASAM recommends the use of drug testing where medically appropriate in clinical treatment settings.
Whereas some patients may initially object to the notion of having to produce urine samples on demand, it is important for patients to understand the therapeutic utility of incorporating urine drug testing into treatment plans. Ideally, the informed consent for treatment obtained at the onset of treatment will include an explicit statement of the role of urine drug testing in the treatment plan.
Positive test results can be useful in intervening with the patient to implement timely alterations in the treatment plan. Urine or saliva drug testing in addiction treatment settings is especially useful in the treatment of individuals who have particular risks of occupational exposure to intoxicants, including health care professionals or workers in occupations involving the manufacture, sale, or serving of alcoholic beverages. Drug testing is also useful to ensure avoidance of use of psychoactive compounds that could have adverse drug interactions with a prescribed medication. In clinical settings where the treating physician has determined that drug testing is indicated, if a patient refuses this aspect of the clinical plan, such refusal should itself become a focus of the treatment plan.
In addiction treatment settings, where it is expected that the patient will be maintaining abstinence while participating in ongoing outpatient or inpatient care, it is appropriate to collect urine for diagnostic purposes to confirm a state of abstinence or to confirm a state of suspected recent use. In such settings, if a patient refuses this aspect of the clinical plan, such refusal should itself become an area of focus in the patient’s the treatment plan. Clinicians have a right to decline to continue to treat a patient for a substance use disorder if the patient refuses to consent to essential components of the treatment plan.
C. The use of drug testing for monitoring purposes.
The frequency and duration of a drug monitoring and testing protocol for a health care professional or other monitored patient should be individualized. All positive screening test results should be verified through confirmatory testing before any adverse action based on test results is taken (e.g., sanctions applied to licensure or privileging). Entities with the power to punish or limit the practices of health care professionals should recognize that substance use per se does not provide sufficient evidence of addiction.
D. The use of drug testing for legal purposes.
When urine, blood or other body fluids are collected for testing for clinical, diagnostic or therapeutic purposes, the test results should be used for such purposes. Release of test results to police departments, prosecutors, or other governmental authorities (e.g., child protection agencies) should occur only under court order or with the authorization of the patient, consistent with federal and state confidentiality regulations.
Physicians should limit their use of drug testing to circumstances of medical necessity. If legal authorities were to request that a physician or a physician’s agent collect a sample of urine, blood, or other body fluids from a person solely for the purpose of aiding in the investigation of a criminal or civil legal proceeding, the physician should inform such nonmedical parties that the patient’s consent or a valid court order is required.
If governmental agencies have legally obtained clinical information from the medical record which includes a positive result from a drug test, ASAM recommends that the detection of an illegal substance in a patient’s urine, blood or other body fluid or tissue should not be considered grounds for prosecution of the patient for ‘drug possession.’
E. The collection, handling and analysis of specimens used in drug testing.
There are various methods for collecting, handling, and analyzing samples of urine or other body fluids for the purpose of detecting the presence of alcohol, nicotine, other drugs, or their metabolites. These include witnessed or unwitnessed specimen collection, chain of custody specimen handling, and screening vs. confirmatory laboratory analysis methods.
Radioimmunoassay (RIA) is a practical and relatively inexpensive method of specimen analysis. It is highly sensitive but lacks some specificity. Confirmation of positive RIA results by gas chromatography/mass spectroscopy provides additional specificity. The specimen collection, handling, and analysis methods used will differ based on the purposes and needs of the clinical plan, and the methods used may also differ based on the purposes and needs of the parties requesting the testing, be they licensing boards, hospitals, or the treating physicians of recovering health care professionals. When screening analysis results are not confirmed by more specific testing, e.g., when cost considerations lead to a decision to not invoke confirmatory testing, issues of test specificity must be recognized.