Drug Testing Is Not Infallible Physicians often worry that innocent people could easily get caught in the drug testing net. Although this is possible, many of these assumptions may be based on misconceptions about testing procedures. One common assumption is that urine testing produces a great number of false-positive results, such as ibuprofen mistaken for cannabinoids, selegiline for amphetamines, and other drugs for opiates or amphetamines. A Medscape poll picked up such statements as, "I am certain that testing for narcotics has false-positives" and "Drug testing has too many false-positives." It has been reported that 5%-10% of such tests produce false-positive results. Gregory Skipper, MD, director of professional health services at Promises Treatment Centers in Santa Monica, California, said that this high rate of false-positives may be the case for the initial screening test, but universal protocols for forensic testing require that all initial positive results be confirmed with a highly accurate second test, using gas chromatography/mass spectrometry or liquid chromatography/mass spectrometry. "The chances of these tests being inaccurate are less than one in a million, and those errors tend to be clerical, not analytical," said Gregory Elam, MD, medical director at National Toxicology Specialists in Nashville, Tennessee, which conducts drug and alcohol testing. Dr Elam and other testing experts say practicing physicians are used to relying only on screening tests for their patients and often don't understand the difference between this test and the confirmatory test. Indeed, a 2007 study[1] of family physicians' interpretations of urine tests of patients for opioids found that they often mistook this difference. The confirmatory test is a requirement in virtually all drug testing. Federal law requires this second test for all mandatory testing and, according to the American Civil Liberties Union,[2] most states require it for all drug testing. C. Everett Koop, MD, the surgeon general in the early years of mandatory drug testing, had no doubts about the confirmatory test. "Current scientific evidence demonstrates that modern drug testing technology and procedures are accurate and reliable," he said in a speech.[3] "False-positives are essentially eliminated." But What If Positives Aren't Retested? However, there is evidence that some organizations are not trying to confirm false-positive findings. In Internet forums, some healthcare workers have claimed that they were immediately dismissed after an initial positive result. Dr Skipper said he doesn't doubt this happens in hospitals, because he has seen it happen with court-mandated testing of known drug abusers."In the nonfederal world, protections can easily be stripped away," he said. Another concern of physicians has to do with what is done with confirmed positives. Some of the drugs that caused a positive result might have been legitimately prescribed—for example, a painkiller. There is also worry that the test-taker wouldn't have a chance to explain. Federal drug testing rules account for this by requiring all positively identified samples to be reviewed by a medical review officer (MRO), a physician who has been trained to investigate drug test results and has the authority to overturn a positive result when an explanation is given. Use of MROs is a widely accepted standard, also adopted by private employers. Dr Elam said that he works as an MRO for many employers, and in this capacity, he has overturned thousands of positive results in his career, independent of the needs of the employer. Rejected results would not be sent to a physician health program (PHP) or medical board, but he said they could still be sent to the employer if the MRO believed the drug "might impede fitness for duty," as in the case of a powerful painkiller. But this elaborate system of safeguards creates another problem: They can be disruptive to the employee and costly for the employer, said Paul Earley, MD, medical director of the Georgia PHP. The confirmatory test result and the MRO's investigation, can take several days, and the individual being investigated has to stop working. For this reason, Dr Earley is skeptical whether random testing can work. "When you do random testing, you can come up with results that you don't know what to do with," he said. "If you screen everyone, you'd better be prepared for a lot of people who have to take time off and need a very expensive evaluation." Some physicians are also concerned about smoking marijuana while on vacation and having it turn up in a drug test. A single use of marijuana can show up on a urine test up to 7 days later, and more frequent use can show up even later—long after any impairment remains. Yul David Ejnes, MD, a Rhode Island internist and former chair of the Board of Regents of the American College of Physicians, thinks that such testing may be an invasion of privacy. "I think what physicians do on their own time is their business," he said, as long as it doesn't intrude on their ability to do their work, doesn't reflect poorly on the profession, and doesn't break the law. Dr Skipper disagreed. "We do hold doctors to a high standard, even on their off-time," he said. "If you're going to practice medicine, part of the deal may be that you're not going to smoke marijuana." Alternatives to Random Drug Testing Physicians have suggested several alternatives to blanket random testing. Limit tests to certain specialties. Dr Ejnes suggested limiting random testing to certain doctors to make it less disruptive and costly. "The testing could be limited to situations where there is a high risk for abuse, such as physicians with access to cartfuls of narcotics." he said. However, this approach doesn't sit well with Julius C. Pham, MD, PhD, an assistant professor at Johns Hopkins University School of Medicine who has studied random testing. "It would be hard to justify limiting tests to certain specialties," he said, noting that every specialty has at least some drug abuse. Experts frequently point to anesthesiology, emergency medicine, and psychiatry, in which there is easy access to drugs, as the specialties with higher-than-average risk for drug abuse, but family physicians also rank near the top, according to a study[4] of physicians with substance abuse disorders in PHPs. Exclude experienced physicians. Some physicians argue that older physicians who have a long track record of sobriety should not have to be tested. But Dr Pham said even veteran doctors cannot be ruled out, because a life-changing incident could set off abuse, or they might have had an abuse problem for many years that they've managed to hide. Test for impairment instead. Other physicians have suggested impairment testing as an alternative to drug testing. Martin Donohoe, MD, an internist in Portland, Oregon, thinks that testing doctors' cognitive and motor skills, which is currently done for some elderly physicians, would better address the reason for drug testing, which is to identify impairment. "In some cases, a doctor may be taking a drug but is not impaired," whereas in other cases, such as sleep deprivation and mental illness, "a doctor may be impaired but is not taking a drug," he said. Dr Skipper, however, disagreed with this approach. Waiting until a physician is impaired, he said, would be too late. "Most physicians who test positive for drugs do not have an impairment yet, and there is still time to take them away from patient treatment before they can harm a patient," he said. Improve security of drugs. A more obvious approach is to make sure drugs are stored and delivered securely, so that they can't be abused in the first place. Michael G. Fitzsimons, MD, who oversees the drug-testing program at Massachusetts General Hospital's anesthesiology department, said many anesthesiologists still don't have tight security procedures. "As a specialty, we could do a lot better with securing substances," he said. Many hospitals use automatic dispensing machines, which vend drugs when a security code is entered and also track utilization. The Mayo Clinic goes even further and strictly accounts for leftover drugs, according to a 2012 article.[5] The drugs must be placed into a secure drop box and are taken to the pharmacy, where the amount of returned drug is checked under video surveillance. Provide more education. Many physicians agree that the profession could be better educated about the dangers of drugs abuse—and about the option for drug-abusing doctors to turn themselves in and enter a confidential rehabilitation program. For example, the residency review committee for anesthesiology requires[6] that residents participate in "educational and scholarly activities" on drug abuse and other impairments. Is Random Testing Really a Good Idea? After all that has been reported on random testing, is it a good idea for doctors? The jury is still out. Dr Pham thinks random testing is a good way of identifying substance-abusing doctors before their impairment gets out of hand. In many cases, he said, these doctors want to get caught. "These are people who know they have a problem," he said. When they are identified, they often say, "Thank you so much for finding me out. I've been struggling with this, and I need help," he said. But Dr Pham still has his doubts whether it will be practical for physicians. "I am in favor of the concept of random testing, but the implementation needs to be studied more carefully," he said. "The logistics and the cost benefits still need to be worked out." For instance, "how do you get someone off work to do the test? You have to arrange coverage for that person, but at the same time it has to be a surprise." Random testing is a matter of "balancing concerns," Dr Pham said. "Do you feel that preserving physician autonomy is more important than preserving the public trust?" Source
