Ethical Use of Drug Testing in the Practice of Addiction Medicine

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Background

Drug testing uses a biological sample to detect the presence of drugs and/or drug metabolites in a patient’s body. Drug tests are ordered by physicians in a range of medical specialties, but drug testing has particular utility in addiction practices.  In clinical addiction medicine, drug testing can provide the treating clinician with objective information about a patient’s recent substance use and feedback for the patient about their disease. The appropriate use of drug testing is an important component of clinical practice as it can help clinicians identify, diagnose, and treat addiction and support patients in recovery. However, drug testing can also be used inappropriately, incorrectly or unethically, leading to potentially adverse outcomes. In recent years, reports of abuses related to drug testing, such as overutilization of drug testing for financial gain, have called into question the quality of available addiction treatment and the motives of addiction treatment providers.

The American Society of Addiction Medicine (ASAM) has developed a consensus document on the Appropriate Use of Drug Testing in Clinical Addiction Medicine,^[i] which provides a broad discussion of drug testing methods, procedures and practices; this policy statement describes ASAM’s position on the ethical use of drug testing in the practice of addiction medicine.

Recommendations:

The American Society of Addiction Medicine recommends:

1. Drug testing is recommended as a therapeutic tool as part of evidence-based addiction treatment. It should not be used or presented as a punitive measure.
• It is problematic to make any clinical decision based on results from presumptive (screening) tests which have not been confirmed by the patient or through the use of definitive testing methods.^[ii] Presumptive tests have significant issues with accuracy because of both false positives and false negatives which can, but should not, affect clinical decision making.
• It is unethical to expel patients from treatment based on drug testing results alone.  Return to use is a common occurrence on the path to recovery and should precipitate a change in a patient’s treatment plan, not expulsion from treatment. The ethical response to a positive drug test result is to discuss the findings with the patient and to consider an evidence-based change in the patient’s treatment plan.
• It is also unethical to expel patients from addiction treatment based solely on a refusal to participate in drug testing.  The ethical response to a patient refusing to participate in adherence testing would be to review with the patient the necessity for prescribers to take appropriate steps to mitigate the risk of diversion and misuse of potentially dangerous medications, and to possibly refer a patient from office-based treatment using agonist pharmacotherapies to a more structured treatment setting such as an opioid treatment program.  
• It is ethical to provide rewards for negative test results as part of contingency management in addiction treatment.
2. Drug testing should be used only when clinically necessary. Tests should be selected based on an individualized clinical assessment of the patient and performed after informed consent whenever possible.
• Clinicians should document the rationale for the drug tests they order and document the clinical decisions they make based on those tests. The use of drug screening panels that test for multiple classes of drugs or multiple compounds within a drug class is a pragmatic approach that can be helpful especially in primary care practices.  Drug testing panels may be pragmatic for new patients in addiction treatment programs, but follow-up testing should be individualized to the patient's history, needs, initial test results, and drugs commonly used in the patient’s geographic location and peer group. (This may not be possible where an external entity such as a governmental agency requires routine testing drug panels to be performed periodically on a set time frame.)
• The use of drug testing panels which apply to every patient at every testing time regardless of the patient’s individual clinical history and needs may not be appropriate because this can result in over- or underutilization of diagnostic services.
3. Presumptive testing should be a routine part of initial and ongoing patient assessment. Definitive testing may be used to detect specific substances not identified by presumptive methods and to refine the accuracy of the test results. Definitive testing may be used when the results are needed to inform clinical decisions where the results will alter the care plan.
• Clinical decisions may be made based on drug test results or on patient self-report of use.  Patient self-report of negative use is often unreliable and positive self-report is complicated by purchasing of illicit drugs that are not consistent or reliable in their components.
• It is inappropriate to order definitive testing for all analytes in every drug test conducted on a patient and to do so repeatedly, without regard to the results from previous tests or the patient’s overall response to addiction treatment interventions.  Ethical use of drug testing requires that the scope of the analyte panel and the frequency of testing be justified by the patient’s clinical status and the ordering clinician’s need for information.
4. Addiction treatment professionals and provider organizations should take appropriate steps to ensure that drug test results remain confidential to the extent permitted by law. Ethical challenges arise when governmental entities require clinicians to share drug test without patient consent, such as when local or state laws require reporting of positive drug test results from pregnant women to child welfare agencies or criminal justice personnel. In these cases, the clinician should be aware of state and local laws and the adverse legal and social consequences of a patient having a positive drug test result. They should disclose such reporting requirements to the patient during the informed consent process prior to initial testing.  At the same time, clinicians disclosing such results under statutory mandates should advocate for their patients when third parties take adverse actions against patients based on drug test results from samples that were not collected or handled according to procedures that meet forensic standards.
5. Clinicians ordering drug tests should be aware of the costs of different testing methods and the financial burden that the patient and society will bear in deductibles, copays, or coinsurance costs.   This is particularly the case when labs performing tests are out-of-network for the patient's health insurance plan, subjecting patients to self-pay for some or all of the costs for drug testing.
6. If clinicians responsible for making clinical decisions based on drug test results do not have training in toxicology, they should have a toxicologist or clinician who is knowledgeable in toxicology such as a Medical Review Officer available for consultation.
7. Clinicians should maintain knowledge of state or federal rules or guidelines about drug testing that may apply to their practice.
8. It is unethical for clinicians or addiction treatment programs to ask laboratories to change cutoff levels to improve that provider’s quality metrics.
9. It is unethical to provide or receive incentives for the use of drug testing independent of a clinical rationale. Thus, fee splitting, the practice whereby a treatment program or sober home orders drug tests and receives a portion of the insurance payment for those tests from the laboratory, is unethical. Furthermore, it is unethical for treatment brokers or other individuals to recruit patients into treatment slots or sober living facility beds with the plan to order clinically unnecessary testing.

Adopted by the ASAM Board of Directors April 3, 2019

    © Copyright 2019. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only without editing or paraphrasing, and with proper attribution to the society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed.

[i] Jarvis M, Williams J, Hurford M, et al. Appropriate Use of Drug Testing in Clinical Addiction Medicine. J Addict Med. 2017:11(3);163-173.

[ii] According to the ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine document, presumptive and definitive testing are defined as follows:

Presumptive testing: In contrast to definitive testing, testing performed using a method with lower sensitivity and/or specificity which establishes preliminary evidence regarding the absence or presence of drugs or metabolites in a sample. The results of presumptive tests are qualitative in that they detect the presence or absence of particular compound, but not their quantity. Immunoassays are good at identifying true negative samples (high sensitivity) and are therefore well suited for use as a screen to eliminate cases from further analysis.

Definitive testing: In contrast to presumptive testing, testing performed using a method with high sensitivity and specificity that is able to identify specific drugs, their metabolites, and/or drug quantities. Definitive testing is likely to take place in a laboratory and each individual test can be expensive. Gas or liquid chromatography combined with mass spectrometry is the gold standard method in definitive drug testing.