There is no universal standard today in clinical toxicology for toxicology testing in addiction treatment. However, toxicology testing can be employed in ways to markedly improve care in three phases of addiction treatment:
Screening and diagnostic evaluation,
Formal treatment, and
Long-term monitoring after initial intensive phases of addiction treatment.
The collection and analysis of body fluids, especially urine samples, for the detection of alcohol, nicotine, other drugs, or their metabolites, is a common protocol of many addiction treatment services. In many cases, effective medical treatment cannot proceed without laboratory testing of this type.
Toxicology testing can be a key component of the initial assessment process for a patient being evaluated for a possible diagnosis of substance-related disorder. Toxicology testing can also be a component of the plan of care during treatment for a substance-related disorder. Toxicology 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.
Due to the sensitive nature of addiction treatment, terminology that is unique to this field of medicine has been adopted by the American Society of Addiction Medicine (ASAM) and is generally accepted within the industry.
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 toxicology testing.
Addiction treatment is a 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).
ASAM POLICY STATEMENT
It is the policy of the American Society of Addiction Medicine (ASAM) that:
Urine toxicology 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 toxicology 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 RECOMMENDED PRACTICES & PROCEDURES
THE USE OF TOXICOLOGY 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.
Toxicology 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 toxicology 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 toxicology 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.
THE USE OF TOXICOLOGY TESTING IN ADDICTION TREATMENT SETTINGS
Toxicology testing is appropriate during inpatient or outpatient addiction treatment, and is particularly appropriate at the onset of a course of treatment. Toxicology 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 toxicology testing can be a part of a clinical protocol or practice guideline in some addiction treatment services. ASAM recommends the use of toxicology 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 toxicology 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 toxicology 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 toxicology 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.
Toxicology 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 toxicology 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 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.
THE USE OF TOXICOLOGY 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.
THE USE OF TOXICOLOGY 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 toxicology 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.”
ADDICTION SCREENING & DIAGNOSTIC EVALUATION
An obvious occasion to employ toxicology testing in addiction medicine is as part of the initial assessment.
Patients presenting for evaluation, and those initially seen for consultation in an emergency department or on in an inpatient hospital unit, should receive a thorough clinical evaluation to establish a diagnosis, including the possibility of a substance use disorder. However, a clinical interview and examination alone should not be considered sufficient, just as the history and physical examination of a patient with a possible diagnosis of diabetes would not be considered sufficient if it did not include laboratory testing.
Toxicology testing provides an objective source of information to compare to the patient’s self-report. In cases where there is a discrepancy between the patient’s subjective report and the objective drug test result, the clinician is in a position to engage the patient over this discrepancy with the goal of enhancing accuracy of the diagnosis and the appropriateness of the treatment plan.
Moreover, toxicology testing is an important clinical tool to assist the evaluating physician, counselor, or other health care professional to determine the risk the individual manifests for acute withdrawal and the indication for withdrawal management (“detoxification”).
Just as a single laboratory assessment is insufficient for detection and management of diabetes or hypertension, monitoring for substance use, including toxicology testing when indicated, should occur throughout the course of medical treatment for a substance use disorder.
The reality in addiction treatment is that toxicology testing is currently underutilized. Many initial assessments, conducted by a counselor or even by an addiction specialist physician, do not include information available from toxicology testing.
Formal programs of intensive treatment, such as partial hospitalization programs or residential programs, as a rule collect specimens for toxicology testing periodically; however, among patients in general outpatient care, it is the exception rather than the rule that data from toxicology testing is gathered on a random basis, over the course of treatment. This is particularly the case in programs serving patients in public sector treatment settings. Initial and ongoing evaluation of a patient’s status in addiction treatment can be accompanied by initial and periodic toxicology testing.
Toxicology testing should be a key component of assessment and treatment planning, especially when integrated with other clinical information gathering, such as a substance use history, physical and mental status examinations, withdrawal severity scores, and standardized laboratory assessments of metabolic, neurologic, and psychiatric status.
A knowledgeable clinician can use toxicology testing to verify self-reports, confirm diagnoses, identify denial and minimization of drug and alcohol use, enhance motivation for treatment, measure biological adaptation, assist in development of treatment planning, monitor treatment response, document treatment effectiveness and outcomes, support patient advocacy by validating abstinence from alcohol and drug use, and validate adherence in taking prescribed controlled substances.
The proper applications of toxicology testing in addiction treatment is critically important and clinicians must recognize that the response to a positive drug test is critical in setting the goals of care.
Toxicology Testing in Addiction Medicine
i. Substance Abuse and Mental Health Services Administration – Drug Testing
ii. American Society of Addiction Medicine – The ASAM Appropriate Use of Drug Testing in Clinical Addiction Medicine
iii. American Society of Addiction Medicine: “Public Policy Statement On Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings”
iv. LabMed: Toxicology in Addiction Medicine
v. Elsevier Health: Toxicology and Drug Testing, An Issue of Clinics in Laboratory Medicine
vi. ResearchGate: Toxicology in Addiction Medicine