BEST PRACTICES IN DRUG TESTING OF HEALTHCARE PROFESSIONALS

Transcription

1 ENSURING COMPLIANCE: EXPLORING BEST PRACTICES IN DRUG TESTING OF HEALTHCARE PROFESSIONALS Martha E. Brown, MD Associate Medical Director, PRN and UF Associate Professor Addiction Medicine Division Disclosures Dr. Brown is a Medical Review Officer and Consultant to Fortes Labs through the University of Florida Dr. Ziegler has no disclosures Penny Ziegler, MD Medical Director, PRN Basic Overview of Drug Testing in PHPs Drug testing is a basic monitoring component of Physician Health Programs (PHPs) Drug testing is one of the ways PHPs use to assure boards that a participant with substance abuse issues is doing well PHPs and licensing authorities have historically considered a history of negative drug tests as synonymous with sobriety and program compliance Basic Overview of Drug Testing in PHPs Although PHPs usually rely on DOT standards in their drug testing programs, there are no national standards or best practices for PHPs which are non-dot programs (and which test for drugs not tested for in DOT programs) There are large variations in frequency of testing, types of testing, and drugs tested for among different state PHPs as demonstrated by our survey of PHPs in 2013 Frequency Testing of 21 PHPs 2013 survey compared with 2006 study 13 PHPs are using approximately the same number of drug tests per year 5 PHPs have increased their drug testing frequencies significantly since PHPs (including Florida) have decreased their drug testing frequencies since 2006 Frequency Testing of 21 PHPs Tests/yr Year 1 Year 2 Year 3 Year 4 Year * * 6* 10* 8* 8* * 6* 3* or > *Multiple programs indicated they are flexible depending on history, compliance, Medical Board stipulations, etc. 1

2 Frequency Testing of 21 PHPs Year Range Median Mode or > 2014 SURVEY or > Overview of Problems PRN has Encountered with Drug Testing Alcohol and drug testing can be beaten and is at best a deterrent Most drugs only detected 1-3 days in urine Individual s metabolism for a drug varies Poppy seeds STILL abound, and some contain more codeine than morphine Low level EtGs STILL abound - I can t find out every ingredient in a dish at a restaurant Overview of Problems PRN Has Encountered with Drug Testing It is expensive to screen for every opiate/drug at once and many of our participants can not afford the testing We sometimes choose (because of cost) to only test for drugs or only for EtG on a given sample Our urines are not observed Not all of our chain of custody forms originate at the collection site; thus participants could possibly collect and ship their own clean urine themselves Overview of Problems PRN Has Encountered with Drug Testing It is incredibly difficult to interpret and deal with some hair tests... No metabolites of cocaine in a participant who has DX of Cocaine Dependency with use in recent past Positive hair test with repeat of hair test two weeks later which is negative Low level codeine with no morphine on routine testing, but positive for morphine on retesting of specimen to level of detection Inability of testing lab to completely remove drugs from surface of hair despite multiple washings You name it, we have seen it! SO WHAT ISSUES HAVE WE BEEN QUESTIONING THIS PAST YEAR? 2

3 Our Test Panels We know more frequent testing and the more drugs tested for, the more likely we will catch someone using or detect an early relapse So, have we increased our testing frequencies and number of drugs tested for in many cases? (Answer: YES) We know the more drugs tested for, the more expensive the test panel. However, do we use different panels for non MDs? (Answer: YES) Does this make us happy? (Answer: NO) What We Regularly Test For EtG/EtS Pot Cocaine Benzodiazepines and their metabolites Amphetamines Opiates including Codeine and Morphine Synthetic opiates including Hydrocodone, Hydromorphone, Oxycodone, Tramadol, etc. What We Regularly* Add On and Not So Regularly** Add On Suboxone* Naltrexone* Ambien* SO WHAT DO WE DO WITH DILUTES? Fentanyl** Anesthesia drugs** Dilute and Out of Range Urines It takes a large amount of consumed water to cause a dilute (on average, a gallon of water consumed over hours) Kidney function and creatinine are part of a very stable system (not easily changed by muscle mass/exercise/food/meat, etc) We quickly eliminate excessive fluids, restoring balance to our system, unless we have kidney disease (which can easily be determined by a nephrologist) Dilute and Out of Range Urines A decrease in the creatinine is the most important and reliable indication of dilution Out of range has only an abnormal specific gravity Dilute has a creatinine of greater than or equal to 2mg/dL and less than 20mg/dL AND a specific gravity greater than but less than

4 Dilute and Out of Range Urines Very difficult to monitor an individual if they constantly have dilute urines Multiple dilute urines are a strong indicator of relapse behavior Testing to detection only shows large number of dilute samples are positive (however, this won t hold up in court) Easy to dilute out an EtG positive Normal creatinine IS NOT 20 mg/dl (20 mg/dl is just the DOT cutoff for dilutes) Normal creatinine IS mg/dl Current Dilute Policy at PRN 1 st -notification of dilute 2 nd -notification and additional urine 3 rd -final notice, 2 added urines, PEth, hair 4 th -referral for urology/nephrology workup, PEth test, and two additional urines 5 th -evaluation, PEth, at least weekly urines for 3 s, and a hair test 6 th -inpatient evaluation, PEth, and observed weekly urines for 12 s Current Dilute Policy at PRN 7 th -results in consideration of whether the case should be closed secondary to noncompliance and DOH notified A participant must have 12 s with no dilute or out of range urines for this policy to re-set We NOW reserve the right to order a PEth, recovery status, or other modality, even on the first dilute urine if we feel circumstances dictate Missed Check-ins Missed call-ins in a 12 period of time will be dealt with in the following manner: 1 st - warning notification 2 nd - warning notification and extra test added 3 rd - final warning notification and extra test added 4 th - evaluation of recovery status Missed Tests after Check-in 1 st -Immediate removal from practice and evaluation of recovery status 2 nd -Voluntary withdrawal from practice posted and inpatient evaluation. May will not return to practice until it is determined they are Fit For Duty and are capable and willing to comply with PRN requirements 3 rd -Closing of file and referral for noncompliance to DOH Frequency Issues 4

5 Urine Frequency Issues We know most drugs/etg have short half lives, therefore many relapses are missed if our frequency of testing is low We have been doing occasional back to back tests and/or testing of worrisome cases following holidays We test (urine, PEth) after a long out-of-country vacations, mission trips We are not currently doing weekend testing We have used hair testing/peth testing for a few individuals instead of urine testing Crosby Frequency Study When urine testing is performed at rate of 8 times a year, probability of testing positive in given even for daily use Infrequent drug use is difficult to detect regardless of DT frequency Ross Crosby, Gregory Carlson, Sheila Specker. Journal of Addictive Diseases, Vol. 22(3) Frequency Study of 48 Hour Detection Window (Mean/SD to positive urine) Drug Use DT 2X a week DT 1X a week DT 2X a DT 1X a 8X a year Every Day 3 +/ / / / /- 40 Every other day 5 +/ / / / /- 52 2X a week 7 +/ / / / /- 81 1X a week 12 +/ / / / / X a 1X a 27 +/ / / / / / / / / /- 817 Other Common Types of Drug Testing PRN is Using PEth Very low or multiple dilutes Missed check-ins Missed tests Recovery status evaluations Initial evaluations After out of country vacations Hair Multiple dilutes Reasonable suspicion Other reasons as outlined above Ross Crosby, Gregory Carlson, Sheila Specker. Journal of Addictive Diseases, Vol. 22(3) Other Common Types of Drug Testing PRN is Using Nails Other reasons as outlined on previous slide When we can t get hair (and you shave all your body hair off) Blood (expensive) when all else fails Hair and Nail Testing Hair grows on average ½ inch per, but there is a lot of variation Still some issues of hair including dying, bleaching, straightening; dark hair binds drugs tighter; incidental exposure? Nail clipping can show drugs up to 8 s Usually doesn t show in hair/nails for 1X use Expensive, but usually done no more than quarterly Less research on hair and nail testing 5

6 Critical Thinking About Indicators of Relapse or Potential Relapses Missed call-ins Missed call-ins, especially on Mondays and Fridays Times of call-ins, especially if they change Low creatinines start to occur Very high creatinine Calling in and finding out one has to test, but then doesn t test ( known missed test ) Critical Thinking About Indicators of Relapse or Potential Relapses All of this requires PHPs to be more viligent about the drug testing stats, such as frequency, time of call-ins, pattern of testing, dilutes, etc., of each participant Continued Questions? How do we better incorporate different methods of testing such as hair, nails, EtG, EtS, PEth, into drug testing programs? What is the best practice in terms of frequency? Can we use other testing modalities besides urine to adequately monitor participants? How do we assure the reliability of our testing, especially if we are not having observed urines? 6