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A commentary on “Urine testing in methadone maintenance treatment: applications and limitations”
Journal of Substance Abuse Treatment 25 (2003) 67 – 68
Discussion
A commentary on ‘‘Urine testing in methadone maintenance treatment: applications and limitations’’ Thinking outside the urine cup Robert L. DuPont, M.D.* Received 25 March 2003; received in revised form 1 April 2003; accepted 10 April 2003
In this useful update of their classic 1970 paper, Goldstein & Brown (2003) make clear that the principal goal for drug testing in Methadone Maintenance (MM) is to deter patients’ non-medical drug use. Urine testing that occurs only occasionally and at predictable times can only hope to identify patients so cognitively impaired from their drug use that they use prohibited drugs in the day or two before the urine test. The authors conclude that not only does urine testing in this way give less information than it appears to about particular patients, but that such urine testing overestimates the performance of the MM programs themselves. Compounding the problems of infrequent and non-random urine testing is the problem of cheating, which is especially significant in MM where patients have abundant incentives to cheat and plenty of time to work out sophisticated strategies to do their cheating. Two good alternatives are suggested by Goldstein and Brown: First, to test urine more often, and second, to do the urine testing on a truly random basis so that each MM patient is at risk for being drug tested every day, even if they were tested the day before. Frequent urine testing is expensive. Random urine testing is impractical for MM patients with extensive take-home privileges. When the authors wrote their original paper on this subject, drug testing was mostly by thin layer chromatography and it was done at large clinical chemistry laboratories which took several days to report their results. Today the immunoassay has become the standard initial urine test and the testing technology has moved on-site which both lowers the cost and gives immediate results. To solve the serious problems posed by infrequent and non-random urine testing, it is necessary to think outside the urine cup. Today, unlike in 1970, there are three practical alternatives: hair, sweat, and saliva. The most widely used
* Corresponding author. Tel.: +1-301-231-9010; fax: +1-301-770-6876. E-mail address: [email protected] (R.L. DuPont). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00103-X
alternative is to test hair, which contains a virtual tape recording of the patient’s drug use over the time the hair was produced. Since head hair grows about half an inch a month, taking a one and one half inch sample of hair gives a measure of the patient’s drug use during 90 days prior to collection. Hair testing will not detect a single episode of drug use in the prior 90 days, but for heroin and cocaine it does not take more than a few uses over that period of time to give a positive test result. On the other hand marijuana is present in lower levels in the hair, so it may take use of marijuana once or twice a week for 90 days to produce a positive hair test for marijuana. Hair testing also permits a roughly quantative measurement of the intensity of drug use over the 90-day period making it possible to tell whether the patient has used heavily, moderately. or lightly over the test period. Hair is an attractive matrix because hair testing is impervious to cheating. In addition, poppy seed consumption does not give a positive test result for opiates in hair, as does a urine test. Hair testing is not without its problems, however. The biggest problem with hair testing is that a single hair test costs about $40 in contrast to the approximately $6 cost of an unconfirmed urine test. However, hair testing does not appear to be so expensive if a once-in-90-days hair test is compared to repeated urine tests over 90 days. Hair testing is more limited than laboratory-based urine testing in the range of drugs tested. Hair cannot be tested for alcohol as urine can. Hair testing does not detect methadone or other synthetic or semi-synthetic opiates not because it is difficult to detect these drugs in hair but because the laboratories have, to this point, focused solely on the five drugs usually tested for in workplace drug tests. The laboratories limit their tests in this way because employers are their biggest customers. Hair testing does reliably detect the use of heroin, cocaine, methamphetamine, and marijuana which are the major concerns of MM treatment. In contrast to onsite urine testing, the MM program staff will not know about
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R.L. DuPont / Journal of Substance Abuse Treatment 25 (2003) 67–68
the patient’s non-medical drug use based on a hair test result until the test is done at the end of a 90-day period. For some MM patients that is a long time to wait to identify nonmedical drug use. On the other hand if urine tests are conducted infrequently then drug use would not be detected by urine testing over an extended period of time either. Sweat is an attractive alternative to urine for follow-up drug testing. Sweat patches, worn like nicotine patches for smoking cessation, can be kept on the skin for up to 3 weeks. Sweat patches, like hair tests, are impervious to cheating. Sweat patch testing usually covers only the SAMHSA-5 drugs. Sweat testing does not include methadone or other synthetic opiates. Like hair testing, sweat testing reliably distinguishes poppy seed use from heroin use and consistently identifies the unique heroin metabolite, 6-acetylmorphine. It is possible now to do on-site oral fluid (or saliva) testing for illegal drugs at costs similar to the costs of on-site urine testing. Oral fluids testing is far better than urine testing when cheating is a concern since oral fluid testing is resistant to cheating. Oral fluids testing has one disadvantage compared to urine testing: oral fluids testing is less effective in identifying marijuana use, because most of the on-site oral fluids tests are not sensitive enough to detect the low levels of marijuana and its metabolites that are usually present in oral fluids. Methadone maintenance and other drug treatment programs need to integrate hair, sweat, and saliva testing into their routine mix of drug testing options in ways that substantially enhance the program’s overall ability to detect non-medical drug use. A full integration of these alternative matrices for drug testing will permit a far more reliable evaluation of the ability of MM programs to deter nonmedical drug use, compared to the occasional non-random urine testing that is now being widely used. One simple example of the application of alternative drug tests occurs in MM treatment when a urine test positive for morphine is thought to reflect poppy seed use. A hair sample will establish whether the use was poppy seeds (which will not give a positive hair test for opiates even on daily poppy seed consumption for 90 days) or heroin use (which will be positive for both morphine and 6-acetylmorphine). Here is another good example of when an alternative to urine testing is appropriate in MM: when a patient is thought to be cheating. A hair test can clear up that question up quickly. An on-site oral fluid test can also be used to deter or detect cheating on urine tests. The MM treatment staff should have the full range of alternative drug testing options available. They should understand the complementary nature of these alternative matrices to the cheaper and more commonly used urine tests (DuPont & Selavka, in press; DuPont & Selavka, 2003). When it comes to the probabilities of detecting occasional drug use with infrequent urine tests two papers published a few years ago considered drug testing in the workplace where typical drug testing frequencies are not
once a week or even once a quarter as they are in MM treatment but usually an average of one random drug test in 2 to 4 years. This study showed that although there are far more occasional users than there are daily users, almost all of the positive drug tests reflect daily or near-daily drug users, rather than occasional users. This fact is important because some critics of workplace drug tests claim that these tests primarily detect very infrequent users of illegal drugs. (DuPont, Griffin, Siskin, Shiraki, & Katze, 1995; DuPont, 1996). Pre-employment drug tests are the most frequently conducted drug tests in the United States. These are the tests that primarily support the drug testing industry. These are all scheduled drug tests in the sense that the prospective employees know on what specific days they will be drug tested. Pre-employment urine tests, with their one to three day detection windows, are truly intelligence tests more than they are drug tests. In MM treatment and in the workplace when cheating is a concern it is useful to go to a matrix that solves this problem. In the context of pre-employment workplace drug tests this is an excellent application for hair testing because of the 90-day detection window. Pre-employment drug tests are a poor application for a urine test with its short detection window. My hope is that the fine paper by Goldstein and Brown will produce some long overdue research on the most costeffective ways to use drug testing in MM treatment. This study must include the full range of drug tests available today and not be restricted to the drug tests that were available in 1970. A similar problem of inertia exists in workplace drug testing where the federal workplace drug test rules now are restricted to the testing technology that was available in 1988 when the regulations were promulgated. Today we need fresh thinking more than ever. It seems to be in very short supply — except for Goldstein and Brown who appear to be refreshingly evergreen when it comes to creativity.
References DuPont, R. L., Griffin, D. W., Siskin, B. R., Shiraki, S., & Katze, E. (1995). Random drug tests at work: The probability of identifying frequent and infrequent users of illicit drugs. Journal of Addictive Diseases, 14, 1 – 17. DuPont, R. L. (1996). Do random workplace drug tests primarily identify casual or regular drug users? MRO Update, July – August, 5 – 7. DuPont, R. L., & Selavka, C. M. (in press). Diagnostic testing — Laboratory and psychological testing. In M. Galanter & H. D. Kleber (Eds.), American Psychiatric Press textbook of substance abuse treatment (3rd ed.). Washington, D.C.: American Psychiatric Press. DuPont, R. L., & Selavka, C. M. (2003). Drug testing in addiction treatment and criminal justice settings. In A. W. Graham, T. K. Schultz, M. F. Mayo-Smith, R. K. Ries, & B. B. Wilford (Eds.), Principles of addiction medicine (3rd ed.). Chevy Chase, MD: American Society of Addiction Medicine. Goldstein, A., & Brown, B. W. (2003). Urine testing in methadone maintenance treatment: Applications and limitations. Journal of Substance Abuse Treatment, 25, 61 – 63.
Discussion
A commentary on ‘‘Urine testing in methadone maintenance treatment: applications and limitations’’ Thinking outside the urine cup Robert L. DuPont, M.D.* Received 25 March 2003; received in revised form 1 April 2003; accepted 10 April 2003
In this useful update of their classic 1970 paper, Goldstein & Brown (2003) make clear that the principal goal for drug testing in Methadone Maintenance (MM) is to deter patients’ non-medical drug use. Urine testing that occurs only occasionally and at predictable times can only hope to identify patients so cognitively impaired from their drug use that they use prohibited drugs in the day or two before the urine test. The authors conclude that not only does urine testing in this way give less information than it appears to about particular patients, but that such urine testing overestimates the performance of the MM programs themselves. Compounding the problems of infrequent and non-random urine testing is the problem of cheating, which is especially significant in MM where patients have abundant incentives to cheat and plenty of time to work out sophisticated strategies to do their cheating. Two good alternatives are suggested by Goldstein and Brown: First, to test urine more often, and second, to do the urine testing on a truly random basis so that each MM patient is at risk for being drug tested every day, even if they were tested the day before. Frequent urine testing is expensive. Random urine testing is impractical for MM patients with extensive take-home privileges. When the authors wrote their original paper on this subject, drug testing was mostly by thin layer chromatography and it was done at large clinical chemistry laboratories which took several days to report their results. Today the immunoassay has become the standard initial urine test and the testing technology has moved on-site which both lowers the cost and gives immediate results. To solve the serious problems posed by infrequent and non-random urine testing, it is necessary to think outside the urine cup. Today, unlike in 1970, there are three practical alternatives: hair, sweat, and saliva. The most widely used
* Corresponding author. Tel.: +1-301-231-9010; fax: +1-301-770-6876. E-mail address: [email protected] (R.L. DuPont). 0740-5472/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00103-X
alternative is to test hair, which contains a virtual tape recording of the patient’s drug use over the time the hair was produced. Since head hair grows about half an inch a month, taking a one and one half inch sample of hair gives a measure of the patient’s drug use during 90 days prior to collection. Hair testing will not detect a single episode of drug use in the prior 90 days, but for heroin and cocaine it does not take more than a few uses over that period of time to give a positive test result. On the other hand marijuana is present in lower levels in the hair, so it may take use of marijuana once or twice a week for 90 days to produce a positive hair test for marijuana. Hair testing also permits a roughly quantative measurement of the intensity of drug use over the 90-day period making it possible to tell whether the patient has used heavily, moderately. or lightly over the test period. Hair is an attractive matrix because hair testing is impervious to cheating. In addition, poppy seed consumption does not give a positive test result for opiates in hair, as does a urine test. Hair testing is not without its problems, however. The biggest problem with hair testing is that a single hair test costs about $40 in contrast to the approximately $6 cost of an unconfirmed urine test. However, hair testing does not appear to be so expensive if a once-in-90-days hair test is compared to repeated urine tests over 90 days. Hair testing is more limited than laboratory-based urine testing in the range of drugs tested. Hair cannot be tested for alcohol as urine can. Hair testing does not detect methadone or other synthetic or semi-synthetic opiates not because it is difficult to detect these drugs in hair but because the laboratories have, to this point, focused solely on the five drugs usually tested for in workplace drug tests. The laboratories limit their tests in this way because employers are their biggest customers. Hair testing does reliably detect the use of heroin, cocaine, methamphetamine, and marijuana which are the major concerns of MM treatment. In contrast to onsite urine testing, the MM program staff will not know about
68
R.L. DuPont / Journal of Substance Abuse Treatment 25 (2003) 67–68
the patient’s non-medical drug use based on a hair test result until the test is done at the end of a 90-day period. For some MM patients that is a long time to wait to identify nonmedical drug use. On the other hand if urine tests are conducted infrequently then drug use would not be detected by urine testing over an extended period of time either. Sweat is an attractive alternative to urine for follow-up drug testing. Sweat patches, worn like nicotine patches for smoking cessation, can be kept on the skin for up to 3 weeks. Sweat patches, like hair tests, are impervious to cheating. Sweat patch testing usually covers only the SAMHSA-5 drugs. Sweat testing does not include methadone or other synthetic opiates. Like hair testing, sweat testing reliably distinguishes poppy seed use from heroin use and consistently identifies the unique heroin metabolite, 6-acetylmorphine. It is possible now to do on-site oral fluid (or saliva) testing for illegal drugs at costs similar to the costs of on-site urine testing. Oral fluids testing is far better than urine testing when cheating is a concern since oral fluid testing is resistant to cheating. Oral fluids testing has one disadvantage compared to urine testing: oral fluids testing is less effective in identifying marijuana use, because most of the on-site oral fluids tests are not sensitive enough to detect the low levels of marijuana and its metabolites that are usually present in oral fluids. Methadone maintenance and other drug treatment programs need to integrate hair, sweat, and saliva testing into their routine mix of drug testing options in ways that substantially enhance the program’s overall ability to detect non-medical drug use. A full integration of these alternative matrices for drug testing will permit a far more reliable evaluation of the ability of MM programs to deter nonmedical drug use, compared to the occasional non-random urine testing that is now being widely used. One simple example of the application of alternative drug tests occurs in MM treatment when a urine test positive for morphine is thought to reflect poppy seed use. A hair sample will establish whether the use was poppy seeds (which will not give a positive hair test for opiates even on daily poppy seed consumption for 90 days) or heroin use (which will be positive for both morphine and 6-acetylmorphine). Here is another good example of when an alternative to urine testing is appropriate in MM: when a patient is thought to be cheating. A hair test can clear up that question up quickly. An on-site oral fluid test can also be used to deter or detect cheating on urine tests. The MM treatment staff should have the full range of alternative drug testing options available. They should understand the complementary nature of these alternative matrices to the cheaper and more commonly used urine tests (DuPont & Selavka, in press; DuPont & Selavka, 2003). When it comes to the probabilities of detecting occasional drug use with infrequent urine tests two papers published a few years ago considered drug testing in the workplace where typical drug testing frequencies are not
once a week or even once a quarter as they are in MM treatment but usually an average of one random drug test in 2 to 4 years. This study showed that although there are far more occasional users than there are daily users, almost all of the positive drug tests reflect daily or near-daily drug users, rather than occasional users. This fact is important because some critics of workplace drug tests claim that these tests primarily detect very infrequent users of illegal drugs. (DuPont, Griffin, Siskin, Shiraki, & Katze, 1995; DuPont, 1996). Pre-employment drug tests are the most frequently conducted drug tests in the United States. These are the tests that primarily support the drug testing industry. These are all scheduled drug tests in the sense that the prospective employees know on what specific days they will be drug tested. Pre-employment urine tests, with their one to three day detection windows, are truly intelligence tests more than they are drug tests. In MM treatment and in the workplace when cheating is a concern it is useful to go to a matrix that solves this problem. In the context of pre-employment workplace drug tests this is an excellent application for hair testing because of the 90-day detection window. Pre-employment drug tests are a poor application for a urine test with its short detection window. My hope is that the fine paper by Goldstein and Brown will produce some long overdue research on the most costeffective ways to use drug testing in MM treatment. This study must include the full range of drug tests available today and not be restricted to the drug tests that were available in 1970. A similar problem of inertia exists in workplace drug testing where the federal workplace drug test rules now are restricted to the testing technology that was available in 1988 when the regulations were promulgated. Today we need fresh thinking more than ever. It seems to be in very short supply — except for Goldstein and Brown who appear to be refreshingly evergreen when it comes to creativity.
References DuPont, R. L., Griffin, D. W., Siskin, B. R., Shiraki, S., & Katze, E. (1995). Random drug tests at work: The probability of identifying frequent and infrequent users of illicit drugs. Journal of Addictive Diseases, 14, 1 – 17. DuPont, R. L. (1996). Do random workplace drug tests primarily identify casual or regular drug users? MRO Update, July – August, 5 – 7. DuPont, R. L., & Selavka, C. M. (in press). Diagnostic testing — Laboratory and psychological testing. In M. Galanter & H. D. Kleber (Eds.), American Psychiatric Press textbook of substance abuse treatment (3rd ed.). Washington, D.C.: American Psychiatric Press. DuPont, R. L., & Selavka, C. M. (2003). Drug testing in addiction treatment and criminal justice settings. In A. W. Graham, T. K. Schultz, M. F. Mayo-Smith, R. K. Ries, & B. B. Wilford (Eds.), Principles of addiction medicine (3rd ed.). Chevy Chase, MD: American Society of Addiction Medicine. Goldstein, A., & Brown, B. W. (2003). Urine testing in methadone maintenance treatment: Applications and limitations. Journal of Substance Abuse Treatment, 25, 61 – 63.