Random Urine Drug Testing

Abstract

To the Editor: Although the desired outcome for Fitzsimons et al.1 was to “reduce the incidence of addiction,” their surrogate marker of success was a reduction in the number of positive urine tests. Care must be taken not to assume that the cost-benefit of random urine testing in a population in which 100% abuse (drug treatment monitoring program) translates to a population in which 1% are substance abusers (anesthesia residency) and justify this assumption with preliminary data.2 The validity of their surrogate marker depends on the compliance of the tested population and the integrity of the urine sample. Both are in question. Only 150 random samples were collected over 4 yr, less than half required by protocol. Their steps to protect the privacy, dignity, and work ethic of the 99% of residents unlikely to be substance abusers created easy opportunities for the remaining 1% to either opt out of testing or provide an invalid specimen. The 36-h response window allows the individual substance abuser time to acquire a urine sample not his/her own or add a urine adulterant or to water load. Write in “pass drug test” on Google to secure overnight delivery of a clean urine specimen or the latest generation of adulterants.3,4 Devices may be purchased to subvert even witnessed collection (“Whizzinator” and “Butt Wedge”).3 In 2004, the Substance Abuse and Mental Health Services Administration published adulterant testing guidelines.5 The Department of Transportation now makes specimen validity testing mandatory.6 Hair sampling, frequently positive in known substance abusers with negative urine tests, bypasses privacy concerns, but is more expensive than urine testing.7 Saliva testing is undergoing validation.8 Successful monitoring programs combine both random testing and behavioral monitoring.9 But approximately 20% of individuals with known drug dependence escape detection based on behavioral monitoring alone.10 Experienced opioid users may self-inject drugs at work with a sufficient dose to prevent withdrawal symptoms but not impair performance and thereby escape detection. The average age of onset for substance abuse is 20 yr.11 Thus, residents whose addiction becomes manifest during residency have gone undetected in medical school and during residency recruitment. Margaret F. Brock, MD Raymond C. Roy, MD, PhD Department of Anesthesiology Wake Forest University School of Medicine Medical Center Boulevard Winston-Salem, North Carolina [email protected]