Should Drug Testing be a Part of Addiction Treatment?

For addiction.com

I had been at the sober house for one week post-rehab when Amanda*, the house mother, swept through the front door with a plastic CVS bag in her hand. “I have to drug-test Lily*,” she said, looking disappointed. Drug tests weren’t routine at the sober house but if the house mother had any suspicions about one of the girls using drugs, she could demand a test at any time.

Lily didn’t pass her test and was immediately kicked out of the house. We knew the consequences of using — each of us had signed an agreement saying we consented to being drug-tested at any time, and that eviction would be the result of a positive test. Still, as Lily packed her bags that evening, the reality of the consequences we had agreed to felt heavy. We eyed the plastic drugstore bag warily, all thinking the same thing: We were one mistake and a CVS trip away from homelessness.

Drug Testing When You’re in Treatment

The American Society of Addiction Medicine (ASAM) “recommends the use of drug testing where medically appropriate in clinical treatment settings.” Drug tests can be administered by testing saliva, blood and hair, though most employers and addiction treatment facilities/rehabs use urine analysis. The most common drug tests, like the one Amanda purchased at the CVS near our sober house, looks for five specific drugs: cannabinoids (marijuana, hash), cocaine (cocaine, crack, benzoylecognine); amphetamines (amphetamines, methamphetamines, speed); opiates (heroin, opium, codeine, morphine); and phencyclidine (PCP).

This is often called the “5-panel test” or the “SAMHSA 5” test because the Substance Abuse and Mental Health Services Administration requires that companies that use commercial car and truck drivers have tests for these drugs in place. Other, more comprehensive forms of drug testing exist but are less common because they’re more expensive. Results from drug tests can be obtained immediately (a breathalyzer, for example), in a matter of minutes (usually with urine analysis) or in several days to weeks (depending on lab response time).

In starting to research this article looking at whether or not drug testing is appropriate and useful in a treatment setting, I admit that I was skeptical of ASAM’s support of testing. I’ve always considered drug testing to be a sort of guerrilla addiction treatment. Perhaps because of my experience in the sober house, for me it had the connotation of being punitive — something that assumes guilt and infantilizes an addict. Testing might be useful in the early days of treatment,, but was passing a test really going to motivate someone to stay sober long-term?

It turns out my conception of both drug testing and addiction treatment was pretty uninformed. “What constitutes ‘successful’ treatment for addiction is going to vary from person to person,” says Ayize Jama-Everett, a certified Harm Reduction Certified Trainer and former director of Thunder Road, an intensive outpatient program in California. “Maybe someone needs help staying clean for six months while they get their life together. Someone else could be trying to get off drugs but not interested in abstaining from alcohol. Drug testing is going to help [an addiction treatment specialist] facilitate dialogue with the client about what their goals for treatment are and how to achieve them.”

Richard S. Schottenfeld, MD, professor of psychiatry at Yale University School of Medicine, whose research focuses on improving the efficacy and accessibility of treatment, thinks of drug testing as much the same as any other kind of health screen. “For good reason, patients treated for hypertension benefit from regular blood pressure testing as way to monitor how well treatment is working and whether there is a need to modify treatment,” he says. “Drug testing serves a similar function in addiction treatment.”

Dr. Schottenfeld finds testing to be an important tool for honest communication between patient and doctor, especially since it can be difficult for an addict who has used to own up to doing so. “Most patients recognize that it will be easy to report accurately about their drug use — as long as they remain abstinent,” he notes. “And most also understand that following a slip or relapse it will be more difficult to report that they used. Many patients are reassured by the plan for regular drug testing because it provides a safety net for them; if they find it too embarrassing, shameful or anxiety-provoking to report a slip or relapse, they have some reassurance that their physician will find out about it and be able to discuss it with them.”

Support vs. Punishment

The key to drug testing as part of successful addiction treatment, as both Jama-Everett and Schottenfeld highlight, is integrating testing as a therapeutic, helpful tool as opposed to a potentially punitive measure. Used well, drug testing allows a health care practitioner and her client to have honest conversations. “If a client comes back with a ‘dirty’ [i.e., positive] drug test, we’re not saying ‘you’re out, your treatment is over,’” Jama-Everett says. Often, it lets the conversation go beyond drug testing — beyond “have you used or haven’t you?” and on to, “What are we going to do about this? Why did this happen? How can we make this treatment more effective for you?”

When I tell Jama-Everett about Lily getting kicked out of the sober house, he shakes his head. “That’s different,” he says, acknowledging there are exceptions in which any drug use turned up by a test can result in serious consequences. “That was a living situation in which one person — the house mother — was responsible for the safety of seven or eight girls, right?” he asks. I nod. “You have to have those kinds of rules in that situation. It’s completely different from a treatment setting where a patient is working [one-on-one] with a professional on an ongoing basis.”

A Better Way to Screen

Of course, how testing is done is extremely important. Schottenfeld recommends starting the tests as early as possible in treatment (tests are administered in many, but not all, inpatient and outpatient treatment programs) and continuing according to a plan agreed to by the patient with his doctor or other provider. Starting drug testing immediately — making it part of treatment from the get-go — helps reduce any offense or mistrust, Schottenfeld explains: “When it is introduced from the beginning as a standard part of treatment for all patients with addiction problems, it doesn’t raise a question about the particular patient’s truthfulness; instead, it shows that the treating clinician understands that many people with an addiction find it very difficult to acknowledge accurately their drug or alcohol use or a slip or relapse.”

I admit that I’ve changed my mind about drug testing. Administered correctly and in the right environment, drug testing can, I believe, be as essential to an addict’s care as monitoring blood glucose levels is for a diabetic’s. And as in any medical situation, it’s essential that doctor and patient have an open, honest dialogue. Drug testing is an unbiased, objective method of facilitating that. Further, it holds the patient accountable for his or her actions — an essential part of any successful long-term recovery. As Jama-Everett says, “I have had clients who have said, ‘Thank you. Thank you for testing me today.’”

*Names have been changed

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