New Drug Testing Guidelines Released

Alicia Ault

July 26, 2017

The American Society of Addiction Medicine (ASAM) has published a consensus document that rounds up the best evidence on when, where, and how to use drug testing in clinical practice.

The guidelines are aimed at addiction specialists, primary care physicians, and any clinicians who would use drug testing. They are not meant to be a substitute for independent clinical judgement, said Lawrence S. Brown Jr, MD, MPH, DFASAM, CEO of START Treatment and Recovery Centers and an ASAM past president, in a July 12 briefing.

Clinicians who want to use drug testing in their practices as a tool to diagnose or monitor treatment of substance use disorders — or to promote recovery — have essentially had to rely on their own research and experience, said Margaret Jarvis, MD, DFASAM, medical director at Marworth, the residential addiction treatment center for the Geisinger Health System.

"We have all adopted our own ways of doing things," said Dr Jarvis. She added that that has created a mishmash that does not help inform how to deliver the best quality of care. "There's such variety in practice that it's hard to know what's best practice," said Dr Jarvis in the briefing.

"Clear standards are always helpful, as they help patients get the best quality care," said Benjamin Nordstrom, MD, PhD, chief clinical officer at Phoenix House, a nonprofit provider of substance abuse services. Standards "also give a layer of protection to providers by assuring them that they aren't far out on a limb in how they are practicing," Dr Nordstrom told Medscape Medical News.

Petros Levounis, MD, chair of the Department of Psychiatry at Rutgers New Jersey Medical School, Newark, New Jersey, said he found the document innovative because "it addresses drug testing not simply as a diagnostic tool" but also "as a therapeutic tool."

The guidelines also address an important question: how to respond to test results, said Dr Levounis, who is a member of the ASAM's board.

It is expected the consensus document will also be helpful to primary care clinicians.

"We certainly would hope that this document would be used not only by specialists but by people who are not specialists who are making the effort to learn how to take better care of the patients that they see who have addiction," said Dr Jarvis. Almost all primary care physicians will see patients who have addictions in their practice, he added.

Most often, health problems are identified in primary care, said Dr Brown. A biological tool such as drug testing should be used in that setting — in part because "there is oftentimes an underestimation with respect to the role that untreated addiction may play in the treating of other chronic diseases, like hypertension and diabetes," he said.

Toward "Smarter" Drug Testing

John Cullen, MD, a family practice specialist in Valdez, Alaska, said it was nice to see additional guidelines and that the consensus was valuable. But, he told Medscape Medical News, guidelines do not appear to offer much more than what is available through the American Academy of Family Physicians' Chronic Pain Management Toolkit.

Dr Cullen's clinic serves an area the size of Ohio; thus, the physicians who practice there are frequently in the position to prescribe opioids and manage substance use disorders, he said.

The ASAM document is more expert opinion than concrete evidence, said Dr Cullen. He said, "The hard thing is, we're still in the situation where we still don't have really good evidence about what best practices are."

The focus of the consensus document is primarily on patients in addiction treatment and recovery, for whom testing is used to assess for indicators of a substance use disorder or to monitor the effectiveness of a treatment plan and support recovery.

"This appropriateness document is designed to guide providers toward 'smarter' drug testing," the authors note. An accompanying article in the Journal of Addiction Medicine further clarifies the rationale.

The guidelines also will help weed out some of the fraudulent and ineffective testing that is occurring, said Dr Brown.

Dr Nordstrom agreed. "Many laboratories will perform reflex confirmation and quantification of all samples, which is lucrative for them but clinically nonsensical," he said.

The document hones in on special populations, such as adolescents, pregnant women, and healthcare and other professionals. Adolescents and pregnant women are often first diagnosed in a general healthcare setting where testing guidelines might be especially helpful.

The consensus statement does not cover workplace testing or drug testing in the context of criminal justice, nor does it cover pain management. Because of the overlap between pain management and addiction, the ASAM did not want to infer that it was suggesting how to manage pain, said Dr Brown.

It includes recommendations on how often and how long to continue testing, according to whether it is in an inpatient or outpatient setting or recovery residence.

A Starting Point

Drug testing can be a starting point for a conversation or a relationship with a patient, Dr Brown said. It needs to be voluntary, he said. "This is not something that we'd recommend be done without patient consent, because if you do, you undermine the benefits of doing the test in the first place," Dr Brown said.

The tests can only measure whether a substance has been used within a certain time frame, and it should be used in combination with a patient's self-reported information about substance use, the guidelines note.

A test result can be informative for the patient, who may not realize the composition of the substances he or she used. It can also be a definitive statement in cases where self-reporting falls short. That discrepancy between the self-report and the test result "can be a point of engagement for the provider."

Drug testing "isn't about having a 'gotcha' moment," said Dr Nordstrom. The tests "aren't lie detectors, and they don't measure a person's truthfulness or worth as a human being," he said. Rather, they "are clinical tests that help providers figure out how much attention and structure a person needs at a given point in their treatment."

The ASAM consensus document was developed using the RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) methodology, which combines the best scientific evidence with field expertise.

The organization's Quality Improvement Council (QIC) appointed a 10-member expert panel representing academic research, internal medicine, adolescent medicine, pain medicine, emergency medicine, medical toxicology, anesthesiology, psychiatry, and obstetrics/gynecology.

The experts came from a range of practice settings, including opioid treatment programs, physician health programs, private practice, and academic medical centers. The expert panel participated throughout the development of the document, including rating treatment scenarios and reviewing the draft.

The ASAM said it attempted to eliminate potential conflicts. All QIC members, expert panel members, and external reviewers were required to disclose all current relevant relationships.

The experts consulted with other medical organizations and reviewed payer policies and the literature. Interestingly, the literature review "revealed that drug testing has rarely been examined for its value as a clinical intervention or as a differential source of information," say the guideline authors.

After discussions and meetings to rate the appropriateness statements that were developed and the external review was completed, a number of different organizations and experts — payers, federal agencies, medical societies, patient advocates, and addiction-related organizations among them — were given the chance to comment.

The ASAM and its consulting partner on the project, the Institute for Research, Education and Training in Addictions, incorporated the comments that were thought to enhance the document, said Dr Brown.

The final consensus was approved by the ASAM board in early April.

Dr Jarvis, Dr Brown, Dr Nordstrom, Dr Levounis, and Dr Cullen have disclosed no relevant financial relationships. Dr Nordstrom is an ASAM member and has served on the organization's expert consensus panel on the use of medications in the treatment of opioid use disorders. Dr Levounis is a member of the ASAM board of directors.

ASAM. Appropriate Use of Drug Testing in Clinical Addiction Medicine. Full text

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