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Random Urine Drug Testing

Section Editor(s): Saidman, LawrenceBrock, Margaret F. MD; Roy, Raymond C. MD, PhD

doi: 10.1213/ane.0b013e3181901da6
Letters to the Editor: Letters & Announcements
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SDC

Department of Anesthesiology; Wake Forest University School of Medicine; Medical Center Boulevard; Winston-Salem, North Carolina; mbrock@wfubmc.edu

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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

mbrock@wfubmc.edu

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REFERENCES

1. Fitzsimons MG, Baker KH, Lowenstein E, Zapol WM. Random drug testing to reduce the incidence of addiction in anesthesia residents: preliminary results from one program. Anesth Analg 2008;107:630–5
2. Levine MR, Rennie WP. Pre-employment urine drug testing of hospital employees: future questions and review of current literature. Occup Environ Med 2004;61:318–24
3. Jaffee WF, Trucco E, Levy S, Weiss RD. Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing. J Subst Abuse Treat 2007;33:33–42
4. Dasgupta A. The effects of adulterants and selected ingested compounds on drugs-of-abuse testing in urine. Am J Clin Pathol 2007;128:491–503
5. Substance Abuse and Mental Health Services Administration. Mandatory guidelines for federal workplace drug testing programs. Fed Regist 2004;69:19644–73
6. Department of Transportation. Procedures for transportation drug and alcohol testing programs. Final rule. Fed Regist 2008;73:35961–75
7. Kintz P, Villain M, Dumestre V, Cirimele V. Evidence of addiction by anesthesiologists as documented by hair analysis. Forensic Sci Int 2005;153:81–4
8. Pil K, Verstraete A. Current developments in drug testing in oral fluid. Ther Drug Monit 2008;30:196–202
9. Katz NP, Sherburne S, Beach M, Rose RJ, Vielguth J, Bradley J, Fanciullo GJ. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg 2003;99:1097–102
10. Hasin DS, Hatzenbueler M, Smith S, Grant BF. Co-occurring DSM-IV drug abuse in DSM-IV drug dependence from the national epidemiologic survey on alcohol and related conditions. Drug Alcohol Depend 2005;80:117–23
11. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psych 2005;62:593–602
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