The Institute on Global Drug Policy and Practice :: Volume 3, Issue 4 – Winter 2010

Drug Testing in Clinical Settings Robert L. DuPont, M.D. President, Institute for Behavior and Health Abstract Drug testing, the pinnacle of modern biotechnology, has evolved beyond urine testing to include testing in hair, saliva, and sweat and has moved out of the laboratory to include on-site testing with results available in a few minutes. Alcohol and drug abusers characteristically lie about their substance use to anyone who might want them to stop their use. Drug testing is now highly reliable in detecting the recent use of specific drugs as well as alcohol, thereby greatly enhancing substance abuse treatment and prevention. Drug testing is also useful in schools and in family-based efforts to prevent drug use. The biology of substance abuse as well as the technology of testing needs to be understood by anyone seeking to use testing to detect the recent use of addicting substances. Keywords Drug Testing, Detection of Drug Use, Addiction, Substance Abuse, Drug Testing in Drug Treatment, Criminal Justice Drug Testing, Toxicology of Drugs of Abuse

I. Introduction: Background
Drugs of abuse are chemicals that hijack the brain’s reward system to produce far more powerful feelings than are produced by the natural rewards of food and sex.(1)  Humans in their relentless exploration of their environments have discovered, and more recently invented, a relatively small number of chemicals that overwhelm the brain’s reward system.  Drug abusers, regardless of the drug they choose or the way they get the drugs into their bodies, seek the effects of these chemicals on their brains.  Since the drugs are carried to the users’ brains in their blood, the drugs are found in all parts of users’ bodies and in all body fluids including urine, saliva and sweat. Drugs are quickly metabolized in the liver and the blood so that even when the drugs themselves are at very low levels their metabolites can sometimes be detected.(2) (3)  Drugs can also be detected in hair, producing a veritable tape recording of drug use in the prior ninety days or even longer.

The same high level of biotechnology is used to detect drugs and their metabolites regardless of the matrix that is tested.  This means that the same high level of reliability is achieved whether the drug test involves blood, urine, oral fluid (saliva), hair or sweat.  The choice of what to test involves consideration of cost, ease of access and the desired detection window.  By far the most common drug testing matrix is urine where the drugs and their metabolites are found in relatively high concentration and where the drug tests can be done without expensive extraction.

Drug testing needs to get beyond the urine cup.  There are important advantages to other matrices in many cases.  Generally, urine identifies drug use in the few hours to 3 days before the test.  Oral fluids have a shorter detection window – generally from a few hours to 1 or 2 days.  While hair tests cannot detect drug use within the week prior to sample collection, a standard inch and a half sample detects drug use in the prior 90 days.  Sweat testing involves wearing a patch similar to the patch worn when stopping smoking.  Sweat patch testing identifies drug use while the patch is worn, usually for 1 to 3 weeks.  Urine is particularly appropriate for frequently repeated random testing (for example in treatment and the criminal justice system).

Hair testing is particularly valuable for scheduled tests, such as pre-employment drug testing, when a detection window beyond 3 days is desirable and when cheating is a risk.  Sweat patch testing is especially valuable immediately following treatment or in initial return to work settings.  Oral fluid testing is especially valuable in many settings where urine is used because it is easier to collect and resistant to cheating.  Roadside testing is an excellent application of oral fluid testing.

Urine is the matrix most subject to cheating, a serious problem that is virtually non-existent with the other matrices.  Drug tests can be done at a laboratory or at the site of collection using on-site drug test kits.  Laboratory testing can be used to test for a wider range of drugs than the other matrices, but results are not available from the laboratory for 1-3 days after the sample was collected.  On-site testing gives results within a few minutes of sample collection.  On-site test kits are available for urine and oral fluid testing but not for hair or sweat testing, both of which are available only through large laboratories.  A more expensive confirming test is possible with either laboratory or on-site drug testing but is seldom needed in clinical settings where testing is frequently repeated and where the consequences of a positive test result are seldom severe.  Most positive drug test results lead to immediate admission of use by the donor.  This is the best confirmation.

Whatever the setting in which drug testing occurs, success is enhanced by using smarter drug testing including testing that rotates the matrix and the drug panel to reduce cheating and to extend the preventive power of the drug tests.  This strategy is described in a related article.(4)

Drug abusers deny recent drug use to anyone who may want to separate them from their drugs.  Drug tests overcome denial and dishonesty.  They are essential to detecting recent drug use in any setting where no-use is the standard.  Without drug tests it is difficult, and often impossible, to identify recent drug use.  In this article we look at drug tests in three settings – treatment, the criminal justice system and the family.  Other articles in this series explore drug testing technology and testing in the workplace and schools.

Drug tests do not identify impairment or addiction.  Drug testing does identify the recent use of specific drugs.  Drug tests are limited and can only identify the specific drugs in their panels; they do not identify “drug use” generally, so when using a drug test it is essential to know what drugs were in the panel that was used.  Use of drugs outside that panel will not be identified, not matter how much of them were used, how recently they were used or how impairing that use was.  Many drug test panels are limited to the SAMHSA-5 drug panel used in federally mandated testing: marijuana, cocaine, morphine/codeine, amphetamine/ methamphetamine, and PCP.  There are many more drugs that are commonly used including Ecstasy, LSD, and a wide range of prescription drugs including Valium, Xanax, Oxycontin and Vicodin.  If abuse of these drugs is suspected, it is essential to include them on the panel of the drug test that is selected.  Although alcohol is most often detected in breath tests, alcohol can also be detected in urine, blood and oral fluids but not in hair or sweat patches.  Because alcohol is rapidly metabolized, these tests are seldom positive more than a few hours after drinking stops.  Nicotine’s metabolite cotenine is detected in urine.

Most illegal drug users, even very severe and chronic users, have been off alcohol and drugs many times – sometimes involuntarily.  Their central problem is not stopping, it is staying stopped.  Put in other words, the clinical challenge for drug abusers is relapse.  Since relapse is a long-term, often lifelong, risk of addicted people, the major challenge of helping these people maintain recovery is to prevent relapse.  Drug testing plays a central role in reducing relapse as it does in drug abuse prevention in schools, workplaces and in many other settings.

II. Clinical Contexts for Drug Testing
Drug testing is useful in any setting in which drug use is a problem.(5) (6) (7) Common settings for drug use include:

1. Substance Abuse Treatment. One of the most important contexts in which drug testing is substance abuse treatment where testing is generally inefficiently used.  The standard for clinical drug testing is set by the nation’s Physician Health Programs (PHPs) which monitor addicted physicians for 5 years or longer.  These programs typically use random drug testing so that on each workday participating physicians call a phone number to see if they need to go in for testing that day.  In the first national study of PHPs, 79 percent of the physicians did not have a single positive test for either alcohol or drugs, and of those who had a positive test, two thirds never had a second positive test.  Treatment programs should adopt similar strategies to insure careful long-term monitoring which produces outstanding long-term outcomes.(8)  Drug testing is not drug abuse treatment, but drug testing makes drug treatment far more successful because it identifies drug use, thereby permitting swift and certain, but not necessarily severe, interventions to stop alcohol and other drug use and to promote long-term recovery.
2. Criminal Justice System. About 5 million Americans are being supervised on parole or probation.  As many as 80% of these convicted offenders have substance abuse problems including alcohol and other drugs of abuse.  This is one of the heaviest drug using and most problem-generating segments of the population of about 20 million American illegal drug users.  New data on frequent random drug testing linked to immediate consequences, as is also true for the PHPs, has been shown to greatly enhance outcomes for offenders in the community.  Prolonged random testing with a zero tolerance for continued substance use not only produces dramatic reductions in alcohol and other drug use but it also produces sharp drops in criminal recidivism and incarceration.(9) (10)
3. Family. While the community at large, schools and pediatricians are important when it comes to drug abuse prevention, the family is ground zero for the prevention of substance abuse.  The family is also a primary location for relapse prevention after substance abuse treatment which rarely lasts more than a year.  Families can improve their success in both prevention and recovery by implementing family-based drug testing – especially for high risk family members.  This often means drug testing teenagers and other family who have had problems with alcohol or other drugs of abuse.  Families need help selecting drug tests and knowing how to handle positive tests results when they occur.  A related article details a strategy for family drug testing.(11)

Families generally do not have access to laboratory-based drug testing unless they use their physician or a teenager’s pediatrician, or a drug treatment program.  However, families have access to drug tests though the Internet and through commercial outlets including most drug stores and many other retail stores.  The drug test kits come with instructions for their use as well as phone numbers where questions can be answered.  The range of drugs tested for with these kits is often very small, so it may be useful to work with a laboratory or a physician to have access to a wider range of drug tests.

When to Test, What to Test for and How to Select a Test Matrix
In each of the three settings described here, it is usually desirable to start with urine testing for a relatively inexpensive panel of 5 to 10 drugs.  These tests are accessible through most clinical laboratories for organizations such as treatment and criminal justice programs.  There are many advantages to expanding the testing to include more drugs both on a rotating basis and when there are concerns about a specific individual’s use of specific drugs that are outside this basic test panel.  There are also advantages to using matrices beyond urine, especially hair and oral fluids in a rotating basis and in special situations including when cheating is suspected since these alternative matrices are resistant to cheating.

When confronted with a result that is difficult to interpret and when the donor of the tested sample convincingly disputes a positive result, it may be desirable to contact the testing laboratory or when using test kits for on-site testing, the manufacturer of the kits that are used.  They have toxicologists available who can interpret the specific result.  As an alternative, it is possible to contact a certified Medical Review Officer (MRO) – a physician who is trained to interpret drug test results.  To find an MRO, please visit the following: American Association of Medical Review Officers (AAMRO) www.aamro.com; Division of Workplace Programs (SAMHSA) http://dwp.samhsa.gov/DrugTesting/; or Medical Review Officer Certification Council (MROCC) www.mrocc.com.  For more information about drug testing visit the Drug and Alcohol Testing Industry Association (DATIA) web site (www.datia.org).

Summary
Drug testing is the pinnacle of modern biotechnology.  Drug testing technology is continuing to improve and to become both more effective and less expensive.  Drug tests identify recent drug use by detecting drugs and their metabolites in urine, oral fluids, hair and sweat.  Drug testing detects only the drugs on the specific panels selected for each test.

The use of drug tests to detect recent drug use is valuable in many clinical settings including substance abuse treatment, the criminal justice system and in the family.  By detecting recent drug use, drug testing plays a central role in prevention, treatment and long-term relapse prevention.

Author Information
Robert L. DuPont, M.D.
President, Institute for Behavior and Health<

For more than 30 years, Robert L. DuPont, M.D. has been a leader in drug abuse prevention and treatment. Among his many contributions to the field is his leadership as the first Director of the National Institute on Drug Abuse (1973-1978) and as the second White House Drug Chief (1973-1978). From 1968 to 1970 he was Director of Community services for the District of Columbia Department of Corrections, heading parole and half-way house services. From 1970 to 1973, he served as administrator of the District of Columbia Narcotics Treatment Administration (NTA), the city-wide drug abuse treatment program that was the model for the federal government’s massive commitment to drug abuse treatment in the early 1970s. Following this distinguished public career, in 1978 Dr. DuPont became the founding president of the Institute for Behavior and Health, Inc.

Dr. DuPont has written for publication more than three hundred professional articles and fifteen books and monographs on a variety of health-related subjects. His books include Getting Tough on Gateway Drugs: A Guide for the Family, A Bridge to Recovery: An Introduction to Twelve-Step Programs and The Selfish Brain: Learning from Addiction. In 2005, Hazelden, the nation’s leading publisher of books on addiction and recovery, published three books on drug testing by Dr. DuPont: Drug Testing in Drug Abuse Treatment, Drug Testing in Schools, and Drug Testing in the Criminal Justice System.

Throughout his decades of work in addiction prevention, Dr. DuPont has served in many capacities. His activities in the American Society of Addiction Medicine (ASAM) include chairing the forensic science committee and he is a Life Fellow. He is also a Life Fellow of the American Psychiatric Association (APA) and was chairman of the Drug Dependence Section of the World Psychiatric Association (WPA) from 1974 to 1979. In 1989 he became a founding member of the Medical Review Officer Committee of ASAM.

A graduate of Emory University, Dr. DuPont received an M.D. degree in 1963 from the Harvard Medical School. He completed his psychiatric training at Harvard and the National Institutes of Health in Bethesda, Maryland. Dr. DuPont maintains an active practice of psychiatry specializing in addiction and the anxiety disorders and has been Clinical Professor of Psychiatry at the Georgetown University School of Medicine since 1980. He is vice president of Bensinger, DuPont and Associates (BDA), a leading national consulting firm dealing with substance abuse, founded in 1982 by Dr. DuPont and Peter Bensinger, former Director of the Drug Enforcement Administration.

Dr. DuPont’s signature role throughout his career has been to focus on the public health goal of reducing the use of illegal drugs.

Conflict of Interest Statement
The author declares that he has no competing interests or conflicts of interest, and that this article was not paid for, inspired, reviewed or edited by a commercial sponsor.

References
1. Volkow ND & Li TK. Drug addiction: The neurobiology of behavior gone awry. In R. K. Ries, D. Fiellin, S. C. Miller & R. Saitz (Eds.)Principles of Addiction Medicine (4th ed., pp. 3-12). Chevy Chase, MD: American Society of Addiction Medicine, 2009.

2. DuPont, R. L. & Selavka, C. M. (In Press). Testing to identify recent drug use. In M. Galanter & H. D. Kleber (Eds.) Psychotherapy for the Treatment of Substance Abuse. The American Psychiatric Press.

3. DuPont, R. L., Goldberger, B. A. & Gold, M. S. (2009). Clinical and legal considerations in drug testing. In R. K. Ries, D. Fiellin, S. C. Miller & R. Saitz (Eds.) Principles of Addiction Medicine (4th ed., pp. 1499-1507). Chevy Chase, MD: American Society of Addiction Medicine.

4. DuPont, R. L. & Graves, H. (2005). Smarter student drug testing. Rockville, MD: Institute for Behavior and Health, Inc. (www.ibhinc.org)

5. DuPont R. L., Newel, R. & Brethen, P. (2005). Drug testing in drug abuse treatment.  Center City, MN: Hazelden.

6. DuPont, R. L. & Brady L. A. (2005). Drug testing in schools: Guidelines for effective use. Center City, MN: Hazelden.

7. DuPont, R. L., Mieczkowski, T. & Newel, R. (2005). Drug testing in the criminal justice system.  Center City, MN: Hazelden.

8. DuPont R. L., McLellan A. T., White W. L., Merlo L., and Gold M. S.  (2009). Setting the standard for recovery: Physicians Health Programs evaluation review. Journal for Substance Abuse Treatment, 36(2), 159-171.

9. Hawken, A. & Kleiman, M. (2008, July). Research brief: Evaluation of HOPE Probation. Retrieved December 1, 2009 fromhttp://www.pewtrusts.org/uploadedFiles/HOPE_Research_Brief.pdf.

10. Long, L. (2009). The 24/7 Sobriety project. The Public Lawyer (17), 2: 2-5.

11. DuPont, R. L. & Bucher, R. H. (2005). Guide to responsible family drug and alcohol testing. Rockville, MD: Institute for Behavior and Health, Inc. (www.ibhinc.org)

www.navgient3.com

via The Institute on Global Drug Policy and Practice :: Volume 3, Issue 4 – Winter 2010.

 

Workplace Testing for Prescription Drugs is Not and ADA Issue – Court Ruling

Bates v. Dura Automotive Systems, Inc.
2009 WL 1108479, No. 1:08-0029
U.S. District Court for the Middle District of Tennessee
April 23, 2009

Facts of the Case: The seven plaintiffs in this case were employees at a manufacturing facility of the defendant, Dura Automotive (Lawrenceburg, Tennessee) that produced glass windows for motor vehicles. While at Dura, the plaintiffs performed many jobs, including the assembly of windows, quality control, and the driving of machinery.

Responding to rumors of widespread drug use, a high rate of accidents, and a specific accident where the injured employees tested positive for drugs, Dura hired Freedom From Self (FFS) to set up a program to test for drug use. Dura decided the program would screen for twelve substances, including legal prescription drugs, which Dura believed could cause some dangerous side effect for operators of machinery and assembly line workers. FFS began to institute the program in May 2007 testing all Dura employees by requiring them to urinate in a cup in a controlled environment. An “initial panel test” would determine presence of any of the twelve banned substances. Any positive test result meant an employee would be sent home indefinitely. 

After a positive result, the urine sample went to a doctor for confirmation. If the positive substance was a legal prescription drug, the employee would be contacted; and if the employee provided a medical explanation, the doctor would change the result to negative and contact Dura. Dura’s human resource manager then would suspend the employee for thirty days to transition to a less risky medication or stop prescription drug use altogether. Moreover, regardless of a change to negative, all employees that originally had a positive result were required by Dura to provide a list of all current prescription drugs to FFS and Dura. Any employee with a positive result could re-take the after 30 days. A clean test would allow them to return to work, but a second positive test would result in automatic termination.

The plaintiffs in this case had an initial positive panel test based on legal prescription drug use, had the result changed by a doctor to a negative result, and received documentation from their doctors indicating the identified prescription medications would not affect work performance. Nonetheless they were suspended for 30-days based on a positive result in the initial panel test or terminated after a second positive test. They brought suit in the U.S. District Court for the Middle District of Tennessee under the Americans with Disabilities Act (ADA) and the Tennessee Disability Act.

Issues of the Case: (1) Whether plaintiffs established a prima facie case of discrimination under the ADA; and (2) whether Dura’s screening test was discriminatory under the ADA.

Arguments & Analysis: 

1. Prima Facie Discrimination Claim Under ADA

The plaintiffs alleged a prima facie discrimination claim under the ADA seeking a reasonable accommodation from Dura. In order to establish a claim of discrimination on the basis of disability under the ADA a plaintiff must show first he/she has a disability, that is: (1) a physical or mental impairment that substantially limits a major life activity, (2) a record of such impairment, or (3) is regarded as having such impairment.  First, the plaintiffs failed to demonstrate a substantial limitation of a major life activity because they were all able to perform their jobs at the time they were terminated by Dura. Second, the plaintiffs did not show that they had a record of impairment merely by demonstrating they needed to miss time to recover from unrelated surgeries and incidents. Third, the fact that Dura regarded the plaintiffs as a safety risk after taking certain medications was insufficient in demonstrating that the plaintiffs were significantly restricted in a class or broad range of jobs such that they were regarded as having a disability by Dura. Since the plaintiffs could not demonstrate a disability, the court rejected this claim, and consequently the plaintiffs were not entitled to reasonable accommodation from Dura. 

2. Was the Screening Test Discriminatory?

Alternately, the plaintiffs argued that the initial panel test was an “impermissible medical examination.” Under the ADA, a covered entity cannot require medical examinations or make inquiries as to whether an employee has a disability unless such an inquiry is “job related and consistent with business necessity.” The ADA forbids “selection criteria that screen out or tend to screen out an individual [or class of individuals] with a disability.” 

The court dismissed the defendant’s argument that the examination did not screen out persons with disabilities, since the test clearly filtered out those persons who had chemicals in their body designed to treat physical and mental disabilities. More significantly, the court dismissed the claim by Dura that the medical screening was “job related and consistent with business necessity.” The business necessity exception allows employers to conduct some medical examinations for the purpose of “workplace safety.” However, the court reasoned that a jury could find the screenings were “broader [and] more intrusive than necessary because Dura automatically excludes all employees that take certain medications from working in any capacity” at the manufacturing plant. 

Additionally, the court noted that it cannot as a matter of law say that the screenings were not consistent with the business necessity exception since the plant is a dangerous workplace environment and Dura only screened drugs that it believed to cause impairment.

Rulings: (1) The court held that the plaintiffs could not establish a prima facie discrimination claim under the ADA because they were not individuals with disabilities. (2) Further the court determined that neither the plaintiffs nor the defendant were entitled to summary judgment on whether the medical screening program was discriminatory as a matter of law. First, the court ruled that a drug policy as expansive as Dura’s, which forbade even prescription drugs that Dura deemed to pose a safety hazard for plant workers, did not as a matter of law fall under the business necessity exception to screening tests under the ADA. Second, the plaintiffs were similarly denied summary judgment since Dura was a dangerous place to work and workplace safety may in many cases trigger the business necessity exception.  Consequently, the case must proceed to a jury for determinations instead of being decided by the court.

Policy & Practice: 

Inflexible Screening Programs May Constitute Violations of the ADA

The reasoning in Bates is consistent with other Sixth Circuit decisions, such as the 2008 decision by the District Court for the Eastern District of Michigan, Wice v. General Motors. That court upheld the General Motors (GM) drug testing program where employees were required to submit to a physical and medical examination if they drove equipment in GM’s plant, but were allowed to have the examination done by their own doctor. The court reasoned that the program was valid since GM did not automatically exclude employees who drove equipment from driving in the plant because of certain medical conditions. Bates also affirms the 2002 Middle District of Tennessee decision in EEOC v. Murray. There, the court did not grant defendant’s motion for summary judgment, where defendant’s drug testing program excluded all persons with certain medical conditions. The court reasoned that the program was not, as a matter of law, compliant with the ADA, since defendant was unable to demonstrate that “all individuals with the specified conditions necessarily exhibit” the limitations that prevent them from performing essential job functions.

This line of cases is drawn from the “business necessity exception” standard as set down by the Second Circuit in Conroy v. New York State Department of Correctional Services. The court there held that the party seeking to show business necessity must demonstrate that the screening program is “vital to the business,” the examination “genuinely serves the asserted business necessity,” and the “request is no broader or more intrusive than necessary.” 

The Bates decision, taken in conjunction with Wice and Murray, suggests that the district courts within the Sixth Circuit are consistently applying this standard. As such, for a drug screening policy to be held valid under the ADA, it appears that courts in the Sixth Circuit require some flexibility in the testing policy, and ultimately that the policy identifies only those individuals that actually are incapable of the essential functions of the job, like safe operation of machinery.
Prepared by the legal research staff of the Burton Blatt Institute (BBI): Centers of Innovation on Disability at Syracuse University (http://bbi.syr.edu/) for the DBTAC: Southeast ADA Center (Southeast DBTAC) (http://www.sedbtac.org/). This document does not provide legal advice. If you have further questions about the issues of this case that relate to you, please consult an attorney licensed in your state.

www.navigent3.com – Advanced Oral Fluid Drug Testing

 

Benefits of Workplace Drug Testing

Benefits of Workplace Employee Drug Testing

In the last 30 years, the practice of employee drug testing has become increasingly prevalent, however, the landscape has changed dramatically.

Traditional 5-panel / DOT / SAMHSA-5 urine laboratory drug testing is outdated and ineffective.  Drug abusers easily defeated this mode of testing and secondly this technique doesn’t account for the abuse of prescription drugs.  The latter is the most significant threat to workplace safety in many situations.

Employers need to effectively test for drugs and alcohol to provide a safe workplace.  Providing a safe workplace is a federal mandate.  Additional benefits from workplace drug testing include higher productivity and lower costs.

Employee drug testing is most effective as a comprehensive approach inclusive of the following:

1. A written, well communicated drug and alcohol policy

2. Drug testing via observed specimen collection:  pre-employment, random (the most effective mode of testing), post-accident, reasonable suspicion, and return-to-duty)

3. Continuous drug and alcohol education

4. Employee assistance programs.

Employers can test for drugs in several ways; however, the most effective and most convenient is oral fluid / saliva drug testing.  This technique is accurate, can be done by employers, and preserves an employee’s dignity.

Urine testing, as noted above is easily defeated by drug abusers.  An hair testing can not detect drug usages within the past seven days, nor can it be used to provide an on-site preliminary result.

 

Drugged Driving – European Research Project – Druid-Project Partner

Partners Involved in European Drugged Driving / DRUID Project

BASt - Bundesanstalt für Straßenwesen (Federal Highway Research Institute), Germany

CDV – Centrum dopravniho vyzkumu (Transport Research Centre), Czech Republic

CERTH-HIT – Centre for research and technology Hellas, Greece

CPS-NILM – Centre of Post-Graduated Studies in Legal Medicine of the National Institute of Legal Medicine of Portugal

DGT - Dirección General de Tráfico, Spain

DRSC – Direkcija Republike Slovenije za ceste, Slovenia

DTU – Danmarks Tekniske Universitet, Denmark

FHI – Norwegian Institute of Public Health, Norway

IBSR - L’Institut Belge pour la Sécurité Routière, asbl, Belgium

IES – Institute of Forensic Research, Poland

IFT - Institut für Therapieforschung, Germany

INRETS – National Institute for Transport and Safety Research, France

ITS – Motor Transport Institute, Poland

KfV - Kuratorium für Verkehrssicherheit (Austrian Road Safety Board), Austria

KLPD – Korps Landelijke Politiediensten, Netherlands

KTL – National Public Health Institute, Finland

LMU - Ludwig-Maximilians Universität München, Germany

RUGPha – University of Groningen, Department of Pharmacotherapy and Pharmaceutical Care, Netherlands

RUGPsy – University of Groningen, Department of Psychology, Netherlands

SIPSiVi - Società Italiana di Psicologia della Sicurezza Viaria, Italy

SWOV – SWOV Institute for Road Safety Research, Netherlands

TFA-UNPD – U.O.C. Tossicologia Forense e Antidoping-Azienda Ospedaliera-Universita di Padova, Italy

TMI – Institute of Forensic Medicine Mykolas Romeris University, Lithuania

TNO – Netherlands Organisation for Applied Scientific Research TNO, Netherlands

TOI – Institute of Transport Economics, Norway

TRC - TÜV Rheinland Consulting GmbH, Germany

UGent – Universiteit Gent, Belgium

UGren - Centre Régional de Pharmacovigilance, France

UKBH – University of Copenhagen, Denmark

UKL-HD - Universitätsklinikum Heidelberg, Germany

UMaas – Maastricht University, Faculty of Psychology, Netherlands

UNICAEN - Université de Caen – Basse Normandie, France

USZ – University of Szeged, Hungary

U. Turku – University of Turku, Finland

UVa - Universidad de Valladolid, Spain

UWUERZ - Bayerische Julius – Maximilians – Universität Würzburg, Germany

VTI - Swedish National Road and Transport Research Institute

ist of Public Deliverables

Deliverables will become accessible via hyperlink as soon as the European Commission releases them for publication.

Work Package 0

Deliverable Name	Lead Participant
Report on the Gender Action Plan	Federal Highway Research Institute, Germany

Work Package 1

Deliverable Name	Lead Participant
Theoretical framework for substance effects on safe driving(pdf 1571-KB)	Bayerische Julius-Maximilians-Universität Würzburg, Germany
Metaanalysis of empirical studies concerning the effects of the most relevant psychoactive substances on safe driving	Bayerische Julius-Maximilians-Universität Würzburg, Germany
The influence of stimulant drugs on actual and simulated driving. This deliverable will incorporate all studies from task 1.2 on stimulant substances	Maastricht University, Faculty of Psychology, Netherlands
Driving performance of medicated and unmedicated patients with sleep/anxiety disorders. This deliverable will include all studies from task 1.2 on medicinal drugs	Maastricht University, Faculty of Psychology, Netherlands
Concentration- impairment functions for the most relevant psychoactive substances based on experimental and epidemiological research	Federal Highway Research Institute, Germany
Synopsis on thresholds – different approaches	Federal Highway Research Institute, Germany

Work Package 2

Deliverable Name	Lead Participant
Prevalence of Psychoactive Substances in the General Population (pdf 567-KB)	Danish Transport Research Institute
Motives behind risky driving	VTI – Swedish National Road and Transport Research Institute
Prevalence of alcohol and other psychoactive substances and consumption patterns in traffic, based on mobile phone interviews in Germany	SWOV – Institute for Road Safety Research, Netherlands
Prevalence of alcohol and other psychoactive substances in drivers in traffic in general in 13 member states	SWOV – Institute for Road Safety Research, Netherlands
Prevalence of alcohol and other psychoactive substances in drivers in fatal accidents in France	Universiteit Gent, Belgium
Prevalence of alcohol and other psychoactive substances in injured drivers, based on hospital surveys in seven member states	Universiteit Gent, Belgium
Relative accident risk of patients using psychotropic medicines in the Netherlands	Danish Transport Research Institute
Relative risk estimates for alcohol and other psychoactive substances-impaired drivers in fatal accidents, based on the responsibility approach in France	Danish Transport Research Institute
Relative risk of impaired drivers who were killed in motor vehicle accidents in Finland (pdf 338-KB)	Danish Transport Research Institute
Comparison of relative risk estimates for alcohol and other psychoactive substances-impaired drivers in fatal accidents in Germany, Sweden and Lithuania	Danish Transport Research Institute
Relative accident risk for impaired drivers based on case control studies in seven member states	Danish Transport Research Institute
Synthesis report: Driving under the influence of alcohol and drugs: Who and how much, risk and responsibility	Danish Transport Research Institute

Work Package 3

Deliverable Name	Lead Participant
Practical evaluation of oral fluid screening devices	TISPOL Organisation, Netherlands
Protocol of “Workshop on drug driving detection by means of oral fluid screening”	Danish Transport Research Institute
Scientific evaluation of oral fluid screening devices and preceding selection procedures	Danish Transport Research Institute
Cost-benefit analysis of drug driving enforcement by the police	Institute of Transport Economics, Norway

Work Package 4

Deliverable Name	Lead Participant
Review of exististing classification efforts (pdf 1083-KB)	Universiteit Gent, Belgium
Establishment of criteria for a European categorisation system for medicinal drugs and driving	University of Groningen, Department of Pharmacotherapy and Pharmaceutical Care, Netherlands
Establishment of framework for classification/categorisation and labelling of medicinal drugs and driving	Universidad de Valladolid, Spain
Classification of medicinal drugs and driving: a synthesis report	Universidad de Valladolid, Spain

Work Package 5

Deliverable Name	Lead Participant
Report on state of the art (pdf 5377-KB)	L’Institut Belge pour la Sécurité Routière, Belgium
Empirical in-depth analysis on recidivism reasons (pdf 5218-KB)	Kuratorium für Verkehrssicherheit, Austria
Development of an integrated evaluation instrument for rehablitation measures (pdf 10137-KB)	Kuratorium für Verkehrssicherheit, Austria
Quality management systems established along with Rehablitation schemes (pdf 962-KB)	Kuratorium für Verkehrssicherheit, Austria
Validation of Existing Rehabilitation Measueres (pdf 1332-KB)	Kuratorium für Verkehrssicherheit, Austria

Work Package 6

Deliverable Name	Lead Participant
Final version of recommendations	Kuratorium für Verkehrssicherheit, Austria

Work Package 7

Deliverable Name	Lead Participant
Report + CD or DVD with examples of ICT supported protocols for prescribing and dispensing of medicines affecting driving performance, and for informing patients who use other psychoactive substances than medicines	University of Groningen, Department of Pharmacotherapy and Pharmaceutical Care, Netherlands
Report on the implementation, evaluation and new technologies of practice guidelines and information materials	Hellenic Institute of Transport

 

Criteria for Selecting an Oral Fluid / Saliva Workplace Drug Test

Characteristic	Definition
Sensitivity	The ability of a method to detect the presence of drugs or classes of drugs.
Speed	The time from start to end of the analytical process using a method.
Simplicity	Usually related to the speed of a method, the requirement for little training for technicians and often associated with highly automated procedures.
Reliability	The dependability of a method. Its ability to reproduce accurate and precise results day-to-day.
Accuarcy	The degree to which a method produces results consistent with actual values.
Precision	The consistency with which a method reproduces results when measuring the same sample.
Economy/Cost	Economic considerations include time of analysis, number of samples processed in a single run, degree of training required of personnel, price of obtaining (and maintaining) instrumentation, price of chemicals and other reagents used in analytical procedure, and overhead of analytical laboratory or other facility.
Safety	The degree to which personnel using a procedure are exposed to risk of injury or long-term toxicity associated with chemicals required by a method.

 

Advantages of On-Site Oral Fluid Drug Screening

On-site drug screening in the workplace and at schools is an important tool to help to identify drug addiction among employees and students, as well as help deter substance misuse.  Performing oral fluid on-site drug screening using multi-panel devices is easy, convenient, and provides virtually instant results. Multi-panel oral fluid drug screens can help to  identify the presence of parent drugs and certain metabolites in single specimen,

Multi-panel on-site oral fluid drug screening can detect a number of drugs present in a sample, without using any additional instrument. The results are easy to read, accurate for an initial qualitative result, and displayed within a period of approximately 10-15 minutes. The multi-panel oral fluid on-site drug screen can detect commonly abused drugs like Cocaine, Amphetamine, Methamphetamine, Marijuana (THC), Opiates-including prescription pain relievers such as Oxycontin, Percoset, Vicodin and Lortab, Phencyclidine, Barbiturates, Benzodiazepine, Methadone, and Ecstasy, as well as alcohol.

A multi-panel on-site oral fluid drug screen is beneficial when multiple drugs presence has to be known quickly. Multi-panel oral fluid drug screening  is very effective when conducted on a  random basis, however, only provide preliminary results. Quantitative methods such as Gas Chromatography\Mass Spectrometry (GC\MS) or LC/MS/MS can be used for confirmatory test purposes.

 

Current Drugs of Abuse Trends

January 2009

Drugs of Abuse / Current Trends

Drug abuse across the United States is as pervasive as it has ever been. As a consequence, it continues to threaten the health and safety of millions of people in the workplace, in our schools, and at persons at large.

Where there may be a growing awareness and concerned about the consequences of drug abuse, the general level of education remains somewhat limited and misunderstanding is common.

Alcohol and Prescription Drugs are represent th most serious threats when combining overall usage rates with impact to workplace safety. With Methamphetamine, Ecstasy, Cocaine, Heroin still being widely used.  In our schools, trending is similar with prescription drugs being the “the drug of choice”, with Inhalants and Steroids also being added to the overall mix.

Drug misuse and be detected and deterred by a combination of:

1. Education

2. Effective drug testing (inclusive of random testing)

3. Assistance programs.

While urine remains the most common drug testing method, it has lost its effectiveness due to the inability to directly observe specimen collection (in most environments), and its inability to detect the widely abuses prescription pain relievers Oxycontin, Percoset, Vicodin, and Lortab in standard ” 5-panel” test configuration.

Oral fluid screening is far more convenient and actually better suited for detecting recent drug misuse.

Hair testing is good for detecting historical drug abuse, however can not detect drug use within the past seven days, and can only be done in a laboratory, vs. on-site.

The Statistics of Drug Abuse in America:

Alcohol:
Alcohol remains the most widely abused drug. According to Federal Reports (NSDUH 2008) , more than half (51.6%) of Americans aged 12 or older abuse alcohol.

Marijuana:
Approximately 15.2 million Americans aged 12 or above abuse alcohol in 2008. Marijuana abusers can be detected between 3 to 5 days using urine tests, but not during the first several hours post consumption, and up to 24 hours using oral fluid, and within minutes of consumption, as well as during the 1 hour impairment period.

Prescription drugs:
There were nearly 6.2 million people aged 12 or older abused prescription drugs in 2008. The most commonly abused prescription drugs are include opioids such as oxycodone and hydrocodone, as well as other sedatives. Most people abuse drugs that are prescribed to their family members.

Methamphetamine:
Methamphetamine is highly addictive stimulant with toxic effects on the central nervous system.  Federal Reports state that there were 314,000 Methamphetamine abusers in 2008. Methamphetamine can be detected in urine for approximately 3 days of the abuse, as well as in oral fluid.

Ecstasy:
Ecstasy (MDMA), also a methamphetamine is a drug of abuse with stimulant and psychodelic properties. There were nearly 555,000 ecstasy abusers in 2008. Ecstasy can be detected in oral fluid or urine.

Cocaine:
Cocaine is highly addictive stimulant drug of abuse. NSDUH states that there were 722,000 persons aged 12 years or above in 2008.  Cocaine can be detected in oral fluid and urine using cocaine test for about 2 to 3 days.

Heroin:
Heroin is an addictive opiate drug, synthesized from morphine. In 2008, there were 114,000 persons aged 12 years or above who had used heroin for the first time within the past one year. Oral fluid and urine tests are preferred to detect heroin abuse for up to  2 to t3 days.

Inhalants:
Inhalants such as volatile solvents, gases, aerosols, and nitrites are breathable chemical vapors, inhaled intentionally to get mind-altering effects.

Steroids:
Athletes mostly use steroids to enhance performance and physical appearance. Steroid abuse can lead to serious health problems.

The above statistics and information are likely under-reported, however show that  drug abuse remains widespread.

It is critical for employers and parents to be aware of the rise and spread of drug abuse. Drug abuse can be reduced and deterred by using reliable, non-punitive drug testing methods, inclusive of education and assistance.  Specimen types for testing/screening include urine, hair, blood or oral fluid.

Urine has fallen out of favor for many employers due to the fact that drug abusers easily defeat this specimen.  In fact, more drug abusers cheat urine tests than there are positives.  On the other hand, innovative employers are adding oral fluid to their drug testing regiments as it can not be “cheated” and more closely parallels results that would be obtained by blood testing. Blood testing is generally regarded as the “gold standard” for all modes of screening/testing.

 

Oral Fluid Screening in the Workplace – Real World Applications

LinkedIn Groups

Group: EHS Professionals Subject: New comment (96) on “drug & alcohol (substance abuse) testing in the workplace – your thoughts?” For me, and for the positives and negatives associated with both types of testing regimes (urine and saliva), i’ll take the saliva with its faults over urine any day. Having set both systems up in operation on large projects numerous times, and being mindful of what the objective of the sampling and testing program are, the saliva tests achieve those results better (for me) than the issues experienced with the urine tests. As selfish as this sounds, I do not care for the person who had a puff of a joint two weeks ago while he was on R&R (which is what the urine test generally caught out in my experiences), i want to stop those people popping the vials and pills over night getting onto my project. I’ll take the few false positives and retests anyday for the ease of the tests for me and my personnel. My range and sampling pool for testing was also increased significantly with the saliva tests. I also got over a significant amount of reluctance from employees as we can all produce saliva on demand – wee on the over hand takes some people a fair amount of time to produce. Taking Renettes’ comments into account, you need to look at what you are trying to get from the program and see which best fits. I strongly advocate a drug and alcohol testing program on worksites. But every person I have caught I (and there unfortunately were a considerable amount over the years) a considered a failure on my behalf for not getting the message through well enough. My biggest issue has always been people coming to work under the influencve of alcohol more than drugs though. www.navigent3.com Advanced Oral Fluid Drug Screening Technology

 

Cut off Concentrations and Workplace Drugs of Abuse

The drug cut off concentration level is the defined level of drug or metabolite concentration in the specimen (blood, hair, oral fluid / saliva , urine , sweat ).

Any concentration of drug or metabolite at or above the cut off level leads to “non-negative” result while below leads to a negative result.

The amount of drug / drug metabolite that can be detected by and on-site screen , laboratory screen , or quantitative confirmatory test (GC/MS, LC/MS/MS) depends on factors like dosage, method of use, time, metabolism, sex, metabolism, frequency of use, specimen type, methods of drug testing, and other factors.

Immunoassay (IA) technique is used to initially screen the specimen ( lateral flow immunoassay for on-site devices) while a Gas Chromatography and Mass Spectrometry (GS/MS), or Liquid (LC/MS/MS) test is conducted for confirmatory testing.

The five most commonly abused drugs are Cocaine, Amphetamines, Marijuana, Opiates, and Phencyclidine (PCP), however, these are ” outdated ” relative to current drug abuse patterns in society.  Prescription drug misuse is the dominant health and safety concern, in addition to alcohol. PCP using is virtually zero.  ” DOT ” testing does not produce “positives” for Oxycontin (Oxycodone ) or Lortab / Vicodine (Hydrocodone).

Urine Drug Testing
In Urine drug testing, the immunoassay (IA) technique is used to perform initial screening of specimen and detect the presence of drugs.

If the concentration of specified drugs is found at or above the cut-off level in initial screening, the results are declared as positive. Later a Gas Chromatography and Mass Spectrometry (GS/MS) test is conducted in laboratory for confirmation.

The initial drug cut off concentration level for five commonly abused drugs using 5-Drug Test Card are:
Cocaine (Benzoylecgonine) — 300 ng/ml
Amphetamines (D-Amphetamine) — 1000 ng/ml
Marijuana (11-nor-?9-THC-9 COOH) — 50 ng/ml
Opiates (Morphine) — 2000 ng/ml
Phencyclidine (Phencyclidine) — 25 ng/ml

The Cut-off levels in urine drug testing are measured in nanograms per milliliter (ng/ml).

The major issues with urine testing is that it is easily and commonly defeated by drug abusers via adulteration and substitution.  Also, traditional five panel tests do not detect the prevalent prescription drugs abused.

Hair Drug Testing
The hair drug testing can show drug abuse history for as long as 90 days, however, has can only be performed at a laboratory, and can not detect drug use within the past week or longer… thus only viable for historical drug abuse.

Furthermore, there are issues with variability in results due to hair color.

The initial drug cut off concentration level for the five commonly abused drugs using 7-panel test are:
Cocaine (Benzoylecgonine) — 0.5 ng/mg
Amphetamines (Amphetamine) — 0.5 ng/mg
Marijuana (cannabinoids) — 0.005 ng/mg
Opiates (Morphine) — 0.2 ng/mg
Phencyclidine (Phencyclidine) — 0.3 ng/mg

The confirmatory drug cut-off levels for these drugs are:
Amphetamines (Amphetamine) — 0.1 ng/mg
Marijuana (cannabinoids) — 0.1 ng/mg
Opiates (Morphine) — 0.1 ng/mg
Phencyclidine (Phencyclidine) — 0.1 ng/mg

Oral Fluid / Saliva Drug Testing
Oral fluid is the proper term, as only 20% of substance in the mouth  is saliva. Oral fluid drug testing is an effective way to detect the presence of drugs consumed in last few days, thus well suited for most employers that are primarily concerned with recent and/or “on-the-job” misuse.  It is also generally concerned superior for post accident or reasonable suspicion testing as it most closely mimics the results obtained from blood testing.

It is convenient, non-invasive, and gives quick results.

The immunoassay technique is used for initial screening of oral specimen for detection of drugs for on-site devices and/or at a laboratory.  A GS/MS or LC/MS/MS test is used for confirmatory purpose if initial screening test is non-negative.

The initial cut off concentration for five common drugs in oral drug testing:
Cocaine (Benzoylecgonine) — 20 ng/ml
Amphetamines (d-Amphetamine) — 50 ng/ml
Marijuana (THC-COOH) — 4-50 ng/ml
Opiates (Morphine) — 20 ng/ml
Phencyclidine (Phencyclidine) — 10 ng/ml

The cut-off concentration, drug class detected, and specimen type are crucial parameters to detect the presence of drugs and conclude whether result is non-negative or negative.

As a non-negative and eventually positive test result can have a significant impact on safety in the workplace as well as providing employee assistance.

www.navigent3.com

 

OSHA Underreports Workplace Accidents – OSHA Responds to GAO Report 2010

WASHINGTON — The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) has responded to the Government Accountability Office (GAO) report on the underreporting of workplace injuries and illnesses and OSHA’s audit process.

The report identifies a number of factors that may contribute to inaccuracy of employer injury and illness records, as well as problems with the audits that OSHA conducts to ensure accuracy.

“Accurate injury and illness records are vital to protect workers’ health and safety,” said Secretary of Labor Hilda L. Solis.

“They not only enable OSHA to better target its resources and determine the effectiveness of its efforts, accurate numbers are also an important tool that workers and employers can use to identify hazards in their workplaces.”

The report identifies worker intimidation as well as a number of disincentives that may discourage workers and employers from reporting work-related injuries and illnesses.

The report also notes widespread reports from occupational health practitioners who said they were pressured not to record an injury or illness.

Acting Assistant Secretary for OSHA Jordan Barab announced that the agency will move swiftly to implement the recommendations made by the GAO. Additionally, in response to the report of underreporting and Congressional interest, OSHA has implemented a National Emphasis Program on Recordkeeping. OSHA will send inspectors into worksites across the country to review the occupational injury and illness records prepared by businesses.

“Many of the problems identified in the report are quite alarming, and OSHA will be taking strong enforcement action where we find underreporting,” Solis said.

For more information, visit www.osha.gov.