Drug Testing: A White Paper of the American Society of Addiction Medicine (ASAM) October 26, 2013 DRUG TESTING: A WHITE PAPER OF THE AMERICAN SOCIETY OF ADDICTION MEDICINE Adopted by the Board of Directors 10/26/2013 © Copyright 2013. American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material, require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only, without editing or paraphrasing, and with proper attribution to the Society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed. American Society of Addiction Medicine 4601 North Park Avenue, Upper Arcade Suite 101, Chevy Chase, MD 20815-4520 TREAT ADDICTION • SAVE LIVES PHONE: (301) 656-3920 • FACSIMILE: (301) 656-3815 E-MAIL: [email protected] • WEBSITE: HTTP://WWW.ASAM.ORG Writing Committee Members Robert L. DuPont, M.D., Committee Chair President, Institute for Behavior and Health, Inc. Corinne L. Shea, MA, Editor Director of Communications, Institute for Behavior and Health, Inc. Members are listed in alphabetical order. Members submitted disclosure forms to the American Society of Addiction Medicine. A table of disclosures is included in the Appendix. Andrea G. Barthwell, M.D., FASAM Jack Croughan, M.D. Founder and Chief Executive Officer Medical Director, Chestnut Health Systems, Two Dreams Outer Banks Bloomington, IL; Private Practice, Addiction Medicine, Louis E. Baxter, Sr., M.D., FASAM St. Louis, MO; President and Executive Medical Director Former Medical Director, Missouri Professional Assistant Program of New Physician’s Health Program, Missouri State Jersey, Inc. Medical Association Al Beaubier Anne Z. DePriest, Pharm.D., BCPS Senior Vice President Senior Scientist for Healthcare Services Bensinger, DuPont & Associates Aegis Sciences Corporation Roger L. Bertholf, Ph.D. Philip J. Dubois Professor of Pathology Executive Vice President Director of Clinical Chemistry, Toxicology DrugScan, Inc.; and Point of Care Testing Chairman-Elect University of Florida College of Drug and Alcohol Testing Industry Medicine/Jacksonville Association Lawrence Brown, Jr., M.D., MPH, FASAM Albert Elian, MS Chief Executive Officer Massachusetts State Police Forensic START Treatment and Recovery Centers, Services Group Brooklyn, NY; Clinical Associate Professor of Public Mahmoud A. ElSohly, Ph.D. Health, Division of Community and Public Research Professor of Pharmaceutics Health Programs University of Mississippi Cornell University National Center for Natural Products Research Kelly J. Clark, M.D., MBA, FASAM, DFAPA J. Ramsay Farah, M.D., MPH, FAAP, Medical Affairs Officer FACPM, FASAM, CPE, CMRO Behavioral Health Group Regional Medical Director, North East United Healthcare Clinical Services; Edward J. Cone, Ph.D. Chief Medical Officer Johns Hopkins University School of Phoenix Health Center, LLC Medicine John Femino, M.D., FASAM Anthony Costantino, Ph.D., D-ABFT Medical Director President and Chief Executive Officer Meadows Edge Recovery Center; DrugScan, Inc. Consultant, Dominion Diagnostics James Ferguson, D.O., FASAM Marilyn A. Huestis, Ph.D. Medical Director Chief, Chemistry and Drug Metabolism Professional Health Monitoring Intramural Research Program FirstLab National Institute on Drug Abuse National Institutes of Health Neil A. Fortner, MS, FTS-ABFT, TC- NRCC, D-ACFE Sharon Levy, M.D., MPH Chief Toxicologist Director, Adolescent Substance Abuse Avee/Alere Toxicology; Program Chairman, Drug and Alcohol Testing Boston Children’s Hospital; Industry Association Assistant Professor of Pediatrics Harvard Medical School David Galbis-Reig, M.D. Director of Medical Services, Inpatient David M. Martin, Ph.D. Addiction Services Chief Executive Officer Wheaton Franciscan Healthcare – All Saints JMJ Technologies, Inc. M.P. George Michael Miller, M.D., FASAM, FAPA Vice President, US Laboratory Operations Medical Director Alere Toxicology Herrington Recovery Center, Rogers Memorial Hospital; Stuart Gitlow, M.D., MPH, MBA, FAPA Clinical Adjunct Associate Professor Associate Clinical Professor of Psychiatry University of Wisconsin School of Medicine Mount Sinai School of Medicine; and Public Health President, American Society of Addiction Medicine Christine Moore, Ph.D., DSc, DABCC Vice President, Toxicology Research and Mark S. Gold, M.D. Development Chairman & Distinguished Professor Immunalysis Corporation Department of Psychiatry; Donald R. Dizney Eminent Scholar Susan F. Neshin, M.D. University of Florida College of Medicine Medical Director JSAS Healthcare, Inc. Bruce A. Goldberger, Ph.D. Professor and Director of Toxicology Michael S. Parr, M.D. Chief, Division of Forensic Medicine Dr. Michael S. Parr & Associates Director, UF Health Forensic Medicine Private Practice Addiction Medicine Departments of Pathology and Psychiatry Sacramento, CA University of Florida College of Medicine Gary Reisfield, M.D. Scott Hambleton, M.D., FASAM Assistant Professor and Chief, Pain Medical Director Management Services Mississippi Professionals Health Program Division of Addiction Medicine and Forensic Psychiatry, Department of Psychiatry Howard Heit, M.D., FACP, FASAM University of Florida College of Medicine Assistant Clinical Professor Georgetown University Gregory J. Rokosz, D.O., J.D., FACEP Gregory Skipper, M.D., FASAM Senior Vice President for Medical and Director of Professional Health Services Academic Affairs Promises Treatment Centers Saint Barnabas Medical Center; Associate Dean and Associate Clinical Michael Tsung, MBA Professor of Emergency Medicine Director of Sales and Marketing Rutgers-New Jersey Medical School Clinigen, Inc. David Sack, M.D. Bernadine T. Tsung-Megason, J.D. Chief Executive Officer Clinigen, Inc. Elements Behavioral Health Norman Wetterau, M.D., FAAFP, FASAM Carl M. Selavka, Ph.D., D-ABC Tricounty Family Medicine Forensic Analytical Chemist and Director Northeastern Bioscience Associates, LLC Robert E. Willette, Ph.D. Duo Research Inc. Laura Shelton, CMP Executive Director Drug and Alcohol Testing Industry Association . Development Process Multiple drafts of the Drug Testing White Paper were developed by the ASAM Drug Testing White Paper Writing Committee. Inputs were collected and integrated into each subsequent draft. Four teleconferences of the Writing Committee were held to explore controversial and/or unresolved issues in the White Paper. This final draft of the White Paper was reviewed by the ASAM Public Policy Committee and ASAM Chapters Council. The Writing Committee integrated the feedback collected from these groups into the culminating White Paper which was reviewed and approved by the ASAM Board of Directors. Table of Contents I. Preface ............................................................................................................................... 1 II. The Science of Drug Testing ............................................................................................... 4 • Box 1: Forensic Drug Testing Versus Clinical Drug Testing ............................................. 6 1. The Evolution of Drug Testing .......................................................................................... 6 2. Drug Testing Technologies .............................................................................................12 • Box 2: LC-MS/MS Drug Testing Technology ..................................................................14 3. The Costs of Drug Testing ..............................................................................................15 4. When to Use Laboratory Definitive Testing .....................................................................18 5. Quantification Using GC-MS or LC-MS/MS .....................................................................20 6. Drug Testing Matrices (Body Fluids/Tissues Analyzed in Drug Tests).............................23 7. Collection and Storage of Samples .................................................................................28 8. Validity Testing of the Specimen .....................................................................................29 9. What Drugs to Test .........................................................................................................31 10. Alcohol Testing ...............................................................................................................34 11. Tobacco Testing .............................................................................................................37 12. Summary ........................................................................................................................38 III. The Practice of Drug Testing ..........................................................................................39 1. Whom to Test and Privacy Considerations .....................................................................39 2. Scheduled