Conflicts among CMHC clinicians over the role of urine drug testing.

Abstract

While urine drug testing is standard practice within addiction treatment,1–2 we know little about its use within community mental health centers (CMHCs)where most treatment occurs for individuals with co-occurring mental illnesses and substance use disorders3. With the advent of affordable, self-reading urine drug screening cups, examining the potential use of urine drug testing in CMHCs is timely. We conducted a survey with 24 bachelor’s and master’s level clinicians experienced in working with co-occurring mental illness and substance use disorders. The study was conducted in the mental health services department within one urban CMHC in which a separate department is state certified for drug and alcohol treatment. Within the mental health services department, urine toxicology testing is conducted at clinician’s discretion and not mandated by state regulations; however, it is mandated within the state certified addiction treatment department. Participants were asked about the extent to which they had utilized, or would like to utilize, urine drug testing and the strengths and challenges associated. To familiarize staff with testing, we provided a supply of self-reading urine test cups and a brief training in their use. The cups were also offered to 31 additional staff in the mental health services department (total N=55). Nearly half (42%) of the 24 survey respondents had used urine drug screening to monitor substance use, though only one had used self-reading test cups. Seven (29%)had used urine drug screening when court-ordered, but very few had used it in any other context. However, many more wanted to use drug tests for a range of treatment purposes including assessing (83%) and treating (71%) substance use, at the request of prescribers (33%), for diagnostic clarification (33%), to show readiness for employment (29%) or housing (17%), and within routine treatment (29%). Clinicians reported that testing could serve as a basis for reinforcement for abstinence, and could also help guide payee ship decisions, identify stages of change, and keep clients ‘honest’ in reporting substance use. The most common concern, raised by about half of the surveyed clinicians (54%), was that testing could worsen the clinical relationship by putting clinicians in a potentially authoritarian role that may remind clients of past experiences with testing in forensic settings. Also, only half of the clinicians (50%) felt that urine drug testing fit within a harm reduction model, while others suggested it was more consistent with an abstinence-only approach. All stressed that testing should be optional and its purpose discussed clearly. Self-reading urine test cups were viewed as an easy and useful way to provide immediate, accurate feedback. However, after three months, only 36% of the 55 clinicians offered the cups had used them. Most had used only one or two cups. Our results showed that while CMHC clinicians reported the utility of urine drug testing, they expressed significant concerns that testing could erode clinical relationships and may be challenging to conceptualize within a mental health recovery and harm reduction framework. While the small sample limits drawing firm conclusions, the study suggests that urine drug testing will not easily be adopted by CMHCs. Regarding the pros and cons of urine drug testing in CMHCs, certain questions should be addressed including, “Do CMHC clinicians view substance use assessment as part of their job?” Are clinicians trained to test for substance use?” “Are drug testing methods available?” “Under what circumstances do clinicians find discretionary testing most useful?” “Do their views differ by type of substance or whether testing for the substance is required within formal addiction treatment settings (such as for medication-assisted opioid treatment)? “How can the clinical utility of urine drug testing be balanced against the perception of stigma and the association of testing with legal consequences?”