Letters to the Editor: Letters & Announcements
The intention of our mandatory random urine testing program1 is not simply to reduce the incidence of positive drug tests, but to produce two important effects improving resident safety: first, to reduce the incidence of dependency, abuse, and misuse of those substances easily available to anesthesiology residents, and second, we aim for earlier detection and treatment of those who do abuse these substances. Only a large randomized trial will allow us to learn which of these effects might be significant. We agree that all incidents of substance misuse will not be detected by substance screening, but we are also impressed with the inability of even the most sensitive and thoughtful of our clinician supervisors to detect residents and fellows who are abusing drugs.
We acknowledge that the 36-h sampling response window does create problems, including the possibility that the urine concentration of a substance may decrease to less than the confirmatory levels. To improve our process, we have reduced this window to 10 h since the publication of our article. We now contact the individual through the paging system early in the morning and require a sample by 5:00 pm that same day.
Brock and Roy2 raised the issue of hair testing since it bypasses privacy concerns. Hair testing allows a longer window of detection than other modes of detection.3 Hair testing may indeed indicate that an individual has ingested a substance, but not whether the individual was under the influence of a substance at a time of patient care. Hair testing requires multiple hairs to be removed. The direct removal of hair is invasive and this action may violate the Fourth Amendment, which bars unreasonable search and seizure.4 The United States Military and the Department of Transportation still monitor urine levels. Urine is considered a waste product and urine testing may be more acceptable.
Brock and Roy2 state that other monitoring programs combine both random testing and behavioral monitoring. Katz et al. describes inappropriate drug use in a population of patients receiving chronic opioids for painful syndromes.5 The importance of this in relation to our program is unclear, since we are attempting to decrease the use of illicit or controlled substances in a population in which usage is abusive and should be nil. The letter also states that experienced opioid users may self-inject drugs at work at a low level sufficient to prevent withdrawal but not at a level to impair performance. We believe such activity would, in fact, argue for the benefits of random drug testing, since performance impairment is not detectable by observers.
Michael G. Fitzsimons, MD
Keith Baker, MD
Edward Lowenstein, MD
Warren Zapol, MD
Department of Anesthesia and Critical Care
Massachusetts General Hospital
1. Fitzsimons MG, Baker KH, Lowenstein E, Zapol, Warren M. Random drug testing to reduce the incidence of addiction in anesthesia residents: preliminary results from one program. Anesth Analg 2008; 107:630–5
2. Brock MF, Roy RC. Random urine drug testing. Anesth Analg 2009;108:676
3. Verstraete AG. Detection times of drugs of abuse in blood, urine, and oral fluid. Ther Drug Monit 2004;26:200–5
4. Issues in employee drug testing. Council on Scientific Affairs. JAMA 1987;258:2089–96
5. 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