Robert L. DuPont, MD, president of the Institute for Behavior and Health and the first director of the National Institute on Drug Abuse (NIDA) in the 1970s, eschews subtlety when discussing his views on the importance of drug testing to addiction treatment services.
“Drug testing is the technology of addiction medicine,” says DuPont. He adds, “It is vastly underutilized, both in terms of prevention and treatment.”
DuPont chaired a committee that last year crafted a white paper on drug testing from the American Society of Addiction Medicine (ASAM). The final document, released by ASAM in December not as a clinical guideline but more as a rallying call for wider use of testing, reflects the strong support for testing that DuPont articulated in a recent interview with Addiction Professional. Here are some of the statements cited in the white paper's conclusions:
- “Although drug testing is not a magic bullet that solves all of the problems associated with substance use disorders, drug testing is essential for the identification of recent drug use in all settings in which drug—and in many cases, alcohol—use is problematic.”
- “Most drug testing panels today include less than 20 drugs, often as few as five. The available testing panels change much more slowly than the rapid changes in the patterns of drug use.”
- “Drug testing must become less expensive and more resistant to subversion.”
Ambivalent attitudes among program staff, often marked by diametrically opposite views within programs about the role and overall importance of testing, create a barrier to effective use of testing as a treatment tool, says DuPont.
He says research supports the premise that attaching meaningful consequences to a positive drug test during treatment ultimately promotes success in treatment. But he adds that programs often fail to maximize their use of testing, some almost to the point of appearing indifferent to remaining informed about a given patient's drug use status.
“In some programs, a lot of the counselors are tough on continued drug use and a lot of the doctors are complete wimps,” says DuPont. And the reverse can be true as well, he adds.
In fact, the white paper points mainly to the medical community as needing to shoulder the major responsibility for realizing the potential of drug testing. “Today's most urgent need is for broader use of drug testing, especially in clinical settings, and for smarter approaches to drug testing, especially by physicians working in addiction medicine and all medical specialties,” the document states.
The white paper makes the case that close communication between physicians and patients, with information delivered in a calm, non-accusatory manner, can reduce patient fears about testing and can make the process constructive while not being unfairly punitive.
DuPont says the content of six hourlong teleconferences involving members of the white paper writing committee generally formed the basis for the report's structure and conclusions.
Expanding the technology
“One of the things we want to do is get people out of the urine cup,” says DuPont. He's not suggesting a wholesale abandonment of urine testing, but an acknowledgment that there are testing alternatives that can address concerns in areas such as the threat of cheating.
“A lot of the testing that is done today is regulated testing, and that is generally limited to urine testing,” DuPont says. “[The Substance Abuse and Mental Health Services Administration] and [the U.S. Department of Transportation] have not issued any matrices for alternatives. That's an embarrassment.”
DuPont adds, “We also want to change the limits of scheduled testing. With pre-employment testing, people know that it's coming. We want to get people to think about random testing.”
The white paper also takes a clear stand that medically supervised use of medication-assisted treatment for addictions should be considered appropriate use. “Patients who are taking methadone, buprenorphine, or naltrexone as prescribed and using it as the doctor intends, they are drug-free—that's in the report,” DuPont says. “Those who continue to use alcohol or marijuana while on methadone, they are not drug-free.”
ASAM states its goal in publishing the paper as one of leveraging today's “impressive drug testing technology” to minimize the many adverse consequences of use, from overdose to addiction to crime to infectious disease.
The paper states, “In particular, wider use of drug testing in health care is needed to identify patients with substance use problems and to get them the help they need to become and stay drug-free. Patients with substance use disorders need to be tested in health care over long periods of time to discourage and to identify relapses. Drug testing needs to become as common in medical practice as clinical diagnostic testing is in the management of hypertension and diabetes.”