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Different settings, different standards

June 01, 2010

Drug testing is almost always used as a primary means of assessing a client upon admission to an addiction treatment program. Following admission, progressive drug testing protocols are needed to ensure that an appropriate level of information, feedback, and reinforcement is available to clients at their current level of recovery, as well as to the clinician striving to provide effective treatment.

As the client's recovery status changes upon completion of successive levels of treatment-inpatient, outpatient, sober living, and aftercare-drug testing protocols must change in terms of sensitivity, frequency, and rationale.

Inpatient treatment

Drug tests are generally administered to all clients upon admission to inpatient treatment programs. These not only provide a baseline from which clinicians can judge a client's progress, but also a check that helps clinicians to see if clients have neglected or forgotten to provide other drug-use information.

“It's a way for us to help assist them with getting honest with what they're doing,” says Jeanne Mahoney, director of nursing at Seabrook House in Seabrook, N.J. “Sometimes it's not that they're lying; they just really don't remember because everything got so chaotic.”

Initial drug tests are typically comprehensive in scope, screening for cocaine, opiates, methadone, THC, amphetamines, PCP, benzodiazepines, barbiturates, and alcohol. However, because these tests usually do not detect Suboxone or buprenorphine use, additional testing may be needed. Additional testing is given to clients who self-report or are suspected of using these substances.

Table. Effective and efficient drug testing protocols in various treatment settings. According to the authors of Hazelden Publishing's Drug Testing in Treatment Settings: Guidelines for Effective Use (Robert L. DuPont, Richard A. Newel, and Paul R. Brethen), there are several options for effective and efficient means of drug testing clients at various levels of treatment.1 Though urine drug testing is the method of choice for the organizations that contributed to this article, the above protocols may also work to achieve the recovery and organizational goals in place at inpatient, outpatient, sober living, and aftercare facilities.

 

Treatment setting

Test administered

Frequency

Rationale

Inpatient

Urine or oral fluid test

One or two times monthly and upon suspicion; randomized

Testing methods provide immediate results; results determine client's commitment to treatment.

Outpatient

Hair test for long term, or urine or oral fluid test upon suspicion

On a routine basis and upon suspicion

Hair tests are cost efficient and only needed four times a year, while urine and oral fluid tests provide immediate results upon suspicion. Testing provides positive reinforcement to client or detection of relapse for organization.

Sober living

Patch test

Upon suspicion

Patch testing provides ongoing monitoring without the collection of many samples; it is too costly for sober living programs to test consistently.

Aftercare

Hair test

Ongoing, infrequent, and random testing, or no testing at all

Clients at this level are responsible for their own recovery, but may need the extra motivation. Hair testing provides long-term results with infrequent sample collection.

Baseline screenings may also be used to identify false reports of substance use. Robin Parsons, director of adult services at Fairbanks in Indianapolis, says that many new patients claim to use a particular drug in order to obtain a certain detox medication. In such cases, baseline drug screens help the clinician evaluate the patient's claims and determine the correct course of detox or treatment.

After this initial, baseline screening, drug testing frequencies may vary from program to program. For instance, while Seabrook House and Fairbanks conduct additional drug tests only for clients suspected of using, Rosecrance in Rockford, Ill., conducts random, daily drug tests on 15 percent of its inpatient population, as well as upon suspicion.

“It's not uncommon for us to do [a drug test] if there are behaviors or information that would [indicate it],” says Parsons. She adds that “the first baseline may be the only drug test a person would receive” because the 24-hour restricted environment makes obtaining substances virtually impossible.

Outpatient treatment

When clients leave the closely-monitored environment of an inpatient program to enter outpatient treatment, drug testing standards typically become more stringent. Seabrook House, Fairbanks, and Rosecrance all report testing their outpatient clients using randomized weekly tests. So, while patients may know that they are going to be tested, they don't necessarily know when. “Obviously, we don't want people to plan and structure their use around a scheduled drug screen,” Parsons says. “For a lot of clients, they will not use just because they know that drug screen is there.”

Seabrook House conducts outpatient urine drug screens with a more sensitive test than that used for inpatient clients. Instead of providing a rapid false or positive result, this test shows clinicians the precise level of substances in a patient's system.

The additional data is important, says Mahoney. “If I test someone on Monday, and I test them again on Friday, that number should be going down. They can't say, ‘Well I'm positive because of last week-you know my urine was positive.’ I can say, ‘But your number was 50, and now it's 60, so what's going on?’”

This sensitive test is more expensive, Mahoney says, but it encourages Seabrook House clients to be honest with themselves. Seabrook House also encourages outpatient clients to be honest with others by giving them the option of sending their drug test results directly to family members or employers. Mahoney says this option has been surprisingly popular.

“It's their safety net,” she says. “[It shows] things are going to be OK because they get their drug test and they have to be honest.”

Because of the volume of drug tests required for outpatient clients, Seabrook House, Fairbanks, and Rosecrance all utilize urine drug tests. In fact, the three report that urine tests are the most common screening method in the continuum of care at their organizations.

“We do urine drug screens mostly because of the number of drug screens that we do,” Parsons says. “We do a lot [of testing] on a daily basis, and that's the most cost-effective way to do it.”

Mahoney agrees: “The cost efficiency is much higher and you get the results right away, but it's also less invasive. Other methods, like drawing blood, are a little more painful.”

Sober living

As in outpatient treatment, drug testing methods and protocols used at sober living facilities must be strict because the client is not under 24-hour supervision. In fact, at Rosecrance, organizational policy dictates that drug tests be given weekly, at random, just as they are in the inpatient and outpatient treatment settings.

“Everyone is made aware of this policy when they are accepted into the [sober living] program,” says David Gomel, senior vice president of adolescent services at Rosecrance. “Urine screens are also conducted for probable cause as deemed necessary or appropriate.”

However, other organizations choose to vary these protocols from patient to patient, based upon the clinician's discretion. For instance, Seabrook House maintains a policy of drug testing sober living participants “as soon as they hit the door” to ensure that these clients haven't used since their release from inpatient or outpatient treatment. But, from that baseline, future testing requirements are undefined.

“It could depend on what's going on in the community, it could be every week, it could be twice a week; it could depend on how long they're there,” Mahoney says. “It depends on where they are in recovery and the relationship with the therapist and how [the therapist] feels the person's doing.”

Fairbanks also allows for clinical discretion to determine the drug testing protocols at its sober living facilities, with one exception: Screening is mandatory for any clients that have gone out on an overnight pass. Fairbanks also maintains a random testing capability in order “to let people know we're paying attention and we care what they're doing.” However, its frequency is not defined.

Fairbanks' Parsons is cognizant of the negative effects from too much drug testing at this level of recovery. “Most of our supportive living programs consist of people in our outpatient program, so we're trying not to double up on them,” Parsons says. “If they're in treatment, they might not get [tested] at all unless their behavior indicates it.”

Aftercare

Once a client completes the continuum of care, drug testing is no longer a necessity, but providers recognize its value as an option for program alumni. Parsons says that although Fairbanks' testing program is optional, “we're there to support people who are done with their treatment and are in ongoing recovery.”

Like Fairbanks, Seabrook House also offers voluntary drug testing for its alumni. But the purpose goes beyond drug testing, says Mahoney. For those who suffer a relapse, “it's about getting them supported and connected to a program. For a lot of clients, it's difficult to come back and share their relapse out of shame or fear of consequences.” But the testing, she adds, “helps us know what's going on with them and get the information we need to help them therapeutically.”

Reference

  1. DuPont RL, Newel RA, and Brethen PR. Drug Testing in Treatment Settings: Guidelines for Effective Use. Center City Minn:Hazelden Foundation, 2005.

Behavioral Healthcare 2010 June;30(6):21-24

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