The maze. Treatment programmes – and the passionate men and women who work in these environments – have long struggled with the decision to introduce a drug testing protocol. It seems too much to consider… Too many articles seem to disagree… Too many different and dubious legal considerations… Too many lab companies showing up in the news as seeming profiteers or criminals… Even stories from our own colleagues seem to be random: they can be good or bad, miracles or hassles. With so many twists and
turns, treatment professionals sometimes feel that they have been dropped in in a maze with no idea where to begin getting out.
The map. This article promises only two things. First, it will show you the map of this maze. It can be daunting to look at. But the second promise is this: a simple, lighted path out of the maze: so simple that you’ll soon forget why were you were lost at all. So hang in there.
The fear: loss of your patients. There is a real fear that, by instituting drug testing procedures, we risk losing our relationship of trust with our patients. In some cases, such as when a patient “pops positive” on their lab report or with a point-of-care device, we fear that we might be faced with the hard decision to dismiss that patient or resident from our programme – or employee from our company. Such ramifications of instituting a drug-testing programme are hard to swallow. So the idea of drug testing your patients or employees is often dismissed out of hand. Justifications for the dismissal are easy to make. They often sound like this: “Testing my patients isn’t in line with my message of a compassionate and trusting environment for recovery. I know him/her, and I would know if they were being honest. Our relationship is strong enough, close enough that I would be able to tell if this person was using, or they would certainly tell me”. Stories like this are so insidious because they are so often true.
The fix: get real (1). Change your words, change your world. As petty as it sounds, the term “drug testing” conjures up negative associations. Do we pass or do we fail? That is a daunting prospect, especially for people in recovery. Recently, labs and medical professionals have tried to alleviate the stigma by using alternative terms like “monitored recovery protocols” or “prescription management evaluation and risk assessment”. The goal isn’t to fool anyone: it’s to shed light on the role of the testing programme – to serve as a tool to aid in recovery by always objectively knowing valuable objective data to guide a person’s treatment from where they actually are, not from where they think they are or say where they are.
The fix: get real (2). Focus on your purpose. Implementing a testing programme has the automatic and immediate effect of focusing a treatment plan. You can identify clear goals for people and distinguish what you are looking for in outcomes. Will you guide treatment based on results? Will you terminate it? It’s up to you. Also, you now have a plan if there is a relapse, the consequences of which you’ve already discussed with your patient up front! This preserves the integrity of your trust-relationship.
The fear: you’re scared stagnant. When the world of medicine acknowledged addiction as a disease, researchers and physicians realised that they could take on addiction using the same methods they were already using to take on disease. They found that addiction, as with other highly complex disorders, can often manifest in varied and unique ways. Unsurprisingly, the population of treatment programmes is thus varied and unique as well, even when patients are battling with similar substances of abuse.
Treatment professionals without objective data to look at and keep track of are human beings. Anybody in any profession can be knocked off their game by something as simple as feeling a bit tired after eating lunch. With the sheer volume of patients and whirlwind of emotions in treatment programmes, it could be possible to accidentally miss a sign of relapse or threat of relapse in your patient. These are watershed moments in the life of a person in recovery, and for the treatment pro it is a precious opportunity to save a life by catching an at-risk client before they spin into a spiral of increasingly destructive or deadly behaviours and substance abuse.
The fix: get simple (1). Use objective data first, instincts second. As with any disease, it is important to know objective data about where a patient is in the recovery process, what they are addicted to, and the level of intoxication that currently exists. As we all know, especially in prescription medications, multiple substances can be used, of which the medical professional needs to be aware to guarantee patient safety.
A screening test is often performed to give an overview of a client’s usage. Most facilities use a Point of Care device that gives a general overview of drug classifications. POC devices identify amphetamines, methamphetimes, barbiturates, buprenorphine (subutex, suboxone), benzodiazepines, cocaine, methadone, MDMA (ecstasy), morphine, opiates, oxycontin, PCP, tricyclics and, recently, EDDP, fentanyl and K2 (spice). These devices can bring you immediate benefits and savings by discouraging diversion and offer tests for $4/£3.60 or lower for larger panel tests. The drawbacks are that the cups are
not always reliable, do not quantify levels of drug present, nor cover all categories of drugs.
Laboratory-based testing, sometimes referred to as “confirmation testing”, is another option and is the most accurate available testing that can show both the levels of drugs in a person’s system as well as exactly which drug is being used. The drawbacks are that laboratory-based testing takes a day or two longer than POC devices to get results so is not necessarily a good option for discouraging diversion, and the cost of these tests is higher than the less-accurate POC cups.
The fix: get simple (2). Protect the life of the person in front of you. People do not always realise that some combinations of drugs can cause harmful, sometimes even fatal, reactions. Patients seeing multiple specialists can, wittingly or unwittingly, omit vital information during their assessment. Conducting a thorough baseline test is done by many facilities to get a “deep dive” into the habits of the patient.
The fear: they’re gunna getchya! The government (gasp!) also has strong opinions about how providers should make their in-office testing decisions. In the US, the Drug Enforcement Agency is a federal law enforcement agency under the Department of Justice, tasked with combating drug smuggling and use in the US. Aside from being the subject of countless legendary crime dramas and action movies, it bears the real and daunting responsibility of monitoring and controlling prescriptiondrug diversion. The DEA is just one of many government entities with a specific set of guidelines on testing programmes. The DHHS (Department of Health and Human Services) has also published opinions about testing, and the conveniently alliterative offices of Medicare and Medicaid have anti-kickback laws on state and federal levels that they are not afraid to use to prosecute unscrupulous individuals and labs. Nor should they be. The UK and elsewhere have equivalent set-ups.
Why they’re scary: a quick history of pee for profit. In the past five years, prescription monitoring has become big business. “Between 2000 and 2009, the total number of CLIA-waived drug tests paid for by Medicare and conducted in physicians‘ offices increased by approximately 3,172,910%” [January 2016 Pain News Network]. Digging into the numbers, we see that only “101 tests were conducted in 2000, and by 2009 that number rose to just over 3.2 million tests. Furthermore, during that same time period and within the specialty of anesthesiology, CLIA-waived drug tests increased 63,687,900%”. The annual cost of drug testing in pain management is estimated at $2billion a year. A November 2014 article in The Wall Street Journal reported that some physicians are making more money from drug testing patients than from treating them.
Millennium Health, the largest drug testing laboratory for pain management providers, was recently fined $256million by the US Department of Justice, then filed for bankruptcy. This led to the discovery that the founders of Millennium Health had taken $1.3billion out of the business in 2014. Ameritox, the second-largest drug testing laboratory, paid physicians to drug test their own patients, and as a result was fined $16.3million by the Justice Department.
It’s easy to understand why the authorities – and insurance companies – have become vigilant in their efforts to reform the business. They’ve pursued this by reducing reimbursements, limiting the frequency of testing, and providing an ever-changing and evolving list of laws for you not to break. But are they practicing medicine by making changes that affect how we treat effectively? Is there a happy medium?
The fix: get reasonable (1). Drug testing is for treatment not for money. The government is always going to want money, but it is not out to get people who want to help their patients. So: help your patients. Take your mind off the money. There is now an exponentially larger level of risk involved with overtesting, or listening to hard-sell reps and labs who recommend unnecessary amounts of testing. It used to be like driving without a seat belt on: maybe you’ll get a ticket but probably not. Now picture a world where not wearing a seatbelt is the equivalent of robbing a bank with no mask on. Law enforcement will probably want that money back, and could get it pretty easily.
The fix: get reasonable (2). Consult an expert. It can be confusing to research and implement a compliant, reasonable way to test. Luckily, there are “good-guy” labs with expert service, whose reps have been trained thoroughly about what the law requires, and what the law prohibits. The reps from the good-guy labs will walk you through how to set up a programme that’s right for your patient population: which drugs to test, when to confirm, a reasonable testing frequency based on your clientele and treatment needs.
The good-guy reps know it all, and they’re happy to help. That’s their play. In truth, they’re as self-serving as any other lab. Because good-guy labs are often smaller boutique services (think the opposite of Quest, Labcorp, Ameritox, Millenium and the like), their management is as terrified of the government as you are. So they make damned sure that their operation is on the straight and narrow all the time regarding compliance. Usually, these guys can also point you in the direction of other compliance-concerned services: health-law oriented lawyers and high quality, trustworthy billers. All this ensures that your programme is quality and still generates a revenue. This time though, it will be a fair revenue based on fair services rendered.
Take a deep breath. Whew. Now that you have the map in your hand, nothing seems so hard, does it? It shouldn’t be. A testing programme should be a no-hassle tool that helps you help your patients, period. So take a deep breath, walk out of that maze. Find yourself a rep who you like, and do something that will protect you, protect your patients and protect your practice: get a testing programme.