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Clinical Drug Testing in Primary Care Clinical Drug Testing in Primary Care Technical Assistance Publication Series TAP 32 Clinical Drug Testing in Primary Care TAP Technical Assistance Publication Series 32 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Clinical Drug Testing in Primary Care Acknowledgments Electronic Access and Copies This publication was prepared for the of Publication Substance Abuse and Mental Health This publication may be ordered from Services Administration (SAMHSA), by SAMHSA’s Publications Ordering Web page RTI International and completed by the at http://store.samhsa.gov. Or, please call Knowledge Application Program (KAP), SAMHSA at 1-877-SAMHSA-7 (1-877-726­ contract numbers 270-04-7049 and 270­ 4727) (English and Español). The document 09-0307, a Joint Venture of The CDM may be downloaded from the KAP Web site at Group, Inc., and JBS International, Inc., http://kap.samhsa.gov. with SAMHSA, U.S. Department of Health and Human Services (HHS). Christina Currier served as the Contracting Officer’s Recommended Citation Representative. Substance Abuse and Mental Health Services Administration. Clinical Drug Testing Disclaimer in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. The views, opinions, and content of this (SMA) 12-4668. Rockville, MD: Substance publication are those of the authors and do Abuse and Mental Health Services not necessarily reflect the views, opinions, or Administration, 2012. policies of SAMHSA or HHS. Originating Office Public Domain Notice Quality Improvement and Workforce All materials appearing in this publication Development Branch, Division of Services except those taken from copyrighted Improvement, Center for Substance Abuse sources are in the public domain and may Treatment, Substance Abuse and Mental be reproduced or copied without permission Health Services Administration, 1 Choke from SAMHSA. Citation of the source is Cherry Road, Rockville, MD 20857. appreciated. However, this publication may not be reproduced or distributed for a fee HHS Publication No. (SMA) 12-4668 without the specific, written authorization Printed 2012 of the Office of Communications, SAMHSA, HHS. ii Contents Chapter 1—Introduction . 1 Audience for the TAP.......................................................1 Organization of the TAP ....................................................1 Reasons To Use Clinical Drug Testing in Primary Care ...........................2 Primary Care and Substance Use Disorders ....................................2 Development of Drug Testing ................................................3 Workplace Drug Testing ....................................................4 Drug Testing in Substance Abuse Treatment and Healthcare Settings ..............5 Differences Between Federal Workplace Drug Testing and Clinical Drug Testing......6 Caution ..................................................................6 Chapter 2—Terminology and Essential Concepts in Drug Testing . 9 Drug Screening and Confirmatory Testing .....................................9 Testing Methods..........................................................10 Test Reliability ...........................................................10 Window of Detection ......................................................11 Cutoff Concentrations .....................................................12 Cross-Reactivity ..........................................................12 Drug Test Panels .........................................................13 Test Matrix ..............................................................14 Point-of-Care Tests .......................................................14 Adulterants .............................................................14 Specimen Validity Tests ...................................................15 iii Clinical Drug Testing in Primary Care Chapter 3—Preparing for Drug Testing . .17 . Deciding Which Drugs To Screen and Test For ................................17 Choosing a Matrix ........................................................17 Specimen Availability ..................................................20 Oral Fluid ............................................................20 Sweat ...............................................................20 Blood ................................................................21 Hair .................................................................21 Breath ...............................................................22 Meconium ...........................................................23 Selecting the Initial Testing Site: Laboratory or Point-of-Care ....................23 Collection Devices .....................................................23 Laboratory Tests ......................................................24 Advantages and Disadvantages of Testing in a Laboratory ....................25 Considerations for Selecting a Laboratory ..................................25 Point-of-Care Tests ....................................................26 Advantages and Disadvantages of POCTs ..................................27 Considerations for Selecting POCT Devices ................................28 Implementing Point-of-Care Testing ......................................29 Preparing Clinical and Office Staffs for Testing .............................30 Preparing a Specimen Collection Site .........................................30 Chapter 4—Drug Testing in Primary Care . 31 Uses of Drug Testing in Primary Care ........................................31 Monitoring Prescription Medication Use ...................................32 Management of Chronic Pain With Opioids.................................32 Evaluation of Unexplained Symptoms or Unexpected Responses to Treatment ....32 Patient Safety.........................................................33 iv Contents Pregnancy ............................................................33 Psychiatric Care ......................................................34 Monitoring Office-Based Pharmacotherapy for Opioid Use Disorders ............ 34 Detection of Substance Use Disorders .....................................34 Initial Assessment of a Person With a Suspected SUD........................35 Talking With Patients About Drug Testing ....................................38 Cultural Competency and Diversity .........................................39 Monitoring Patients ......................................................40 Patients With an SUD ..................................................40 Monitoring Patients Receiving Opioids for Chronic Noncancer Pain .............41 Ensuring Confidentiality and 42 CFR Part 2...................................42 Preparing for Implementing Drug Testing.....................................43 Collecting Specimens ...................................................43 Conducting POCTs ....................................................44 Interpreting Drug Test Results .............................................44 Result: Negative Specimen ..............................................45 Result: Positive Specimen ...............................................46 Result: Adulterated or Substituted Specimen ...............................47 Result: Dilute Specimen ................................................48 Result: Invalid Urine Specimen ..........................................48 Frequency of Testing ......................................................49 Documentation and Reimbursement .........................................49 Documentation ........................................................49 Reimbursement .......................................................50 Chapter 5—Urine Drug Testing for Specific Substances . .51 . Window of Detection ......................................................51 Specimen Collection .......................................................52 v Clinical Drug Testing in Primary Care Adulteration, Substitution, and Dilution ......................................52 Adulteration .........................................................52 Substitution ..........................................................53 Dilute Specimens ......................................................53 Cross-Reactivity ..........................................................54 Alcohol .................................................................54 Amphetamines ...........................................................55 Barbiturates .............................................................56 Benzodiazepines..........................................................56 Cocaine .................................................................57 Marijuana/Cannabis ......................................................58 Opioids .................................................................58 Other Substances of Abuse .................................................60 PCP .................................................................60 Club Drugs ...........................................................60 LSD .................................................................61 Inhalants ............................................................61 Appendix A—Bibliography . .63 . Appendix B—Laboratory Initial Drug-Testing Methods . .71 . Appendix C—Laboratory Confirmatory Drug-Testing Methods . .73 . Appendix D—Laboratory Specimen Validity-Testing Methods .
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