Drug Testing of Pregnant Patients

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Ethnoracial differences in workplace drug testing and policies on positive drug tests in the United States

BACKGROUND

Drug testing is widely implemented as a work-based prevention strategy for employee substance use. However, it has raised concerns about its potential use as a punitive measure in the workplace where racialized/ethnic workers are over-represented. This study examines the rates of exposure to workplace drug testing among ethnoracial workers in the United States and the potential differences in the employers' responses to positive test results.

METHODS

A nationally-representative sample of 121,988 employed adults was examined using the 2015-2019 National Survey on Drug Use and Health data. The rates of exposure to workplace drug testing were estimated separately for ethnoracial workers. Then we used multinomial logistic regression to test differences in employers' responses to the first positive drug test results across ethnoracial subgroups.

RESULTS

Since 2002, Black workers reported 15-20% points higher rates of having a workplace drug testing policy than Hispanic or White workers. When tested positive for drug use, Black and Hispanic workers were more likely to be fired than White workers. When tested positive, Black workers were more likely to be referred to treatment/counseling services while Hispanic workers were less likely to be referred compared to White workers.

CONCLUSION

Black workers' disproportionate exposure to drug testing and punitive responses in the workplace may potentially place individuals with substance use problems out of the workforce, limiting their access to treatment/other resources available via their workplaces. Also, Hispanic workers' limited accessibility to treatment and counseling services when tested positive for drug use requires attention to address unmet needs.

An Argument Against Drug Testing Welfare Recipients

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous-aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

Ethical Issues Raised by Epigenetic Testing for Alcohol, Tobacco, and Cannabis

Epigenetic testing is one of the most significant new technologies to provide insight into the behavioral and environmental factors that influence the development and reconfiguration of the human genetic code. This technology allows us to identify structural changes in the genome that occur due to exposure to a wide variety of substances including alcohol, tobacco, and cannabis. The information gained can be used to promote health but it also raises a variety of ethical, legal, and social issues. As society progresses in understanding the epigenetic mechanisms of substance use and addiction, there is an opportunity to use these use this knowledge to enable medical, behavioral, and environmental interventions to alleviate the burden of addiction. This article describes the ethical issues associated with use of epigenetic testing for alcohol, tobacco, and cannabis and the implications of this technology. A further review of the scientific basis for the relevance of epigenetics is found in the accompanying article by Philibert and Erwin in this issue.

What's trust got to do with it? Revisiting opioid contracts

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are 'drug seeking', 'abusing' and 'diverting' prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient-physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient-physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient-physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients' subjective knowledge in enhancing physicians' self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain.

Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

Various kinds of alcohol and drug testing, such as preemployment, routine, and for-cause testing, are commonly performed by employers. While healthcare organizations usually require preemployment drug testing, they vary on whether personnel will be subjected to further testing. Recently, a call has gone out for postincident testing among physicians who are involved in serious, preventable events, especially ones leading to a patient's death. This article will offer a number of counterarguments to that proposal and discuss an alternate approach: that health institutions can better improve patient safety and employees' well-being by implementing an organizational policy of "speaking up" when system operators notice work behaviors or environmental factors that threaten harm or peril. The article will conclude with a description of various strategies that facilitate speaking up, and why the practice constitutes a superior alternative to mandatory alcohol and drug testing in the wake of serious, harm-causing medical error.

Reducing the harmful effects of alcohol misuse: the ethics of sobriety testing in criminal justice

Alcohol use and abuse play a major role in both crime and negative health outcomes in Scotland. This paper provides a description and ethical and legal analyses of a novel remote alcohol monitoring scheme for offenders which seeks to reduce alcohol-related harm to both the criminal and the public. It emerges that the prospective benefits of this scheme to health and public order vastly outweigh any potential harms.

Trauma activation patients: evidence for routine alcohol and illicit drug screening

Background

Statistics from the National Trauma Data Bank imply that discretionary blood alcohol and urine drug testing is common. However, there is little evidence to determine which patients are appropriate for routine testing, based on information available at trauma center arrival. In 2002, Langdorf reported alcohol and illicit drug rates in Trauma Activation Patients.

Methodology/Principal Findings

This is a retrospective investigation of alcohol and illicit drug rates in consecutive St. Elizabeth Health Center (SEHC) trauma patients. SEHC Trauma Activation Patients are compared with the Langdorf Activation Patients and with the SEHC Trauma Nonactivation Patients. Minimum Rates are positive tests divided by total patients (tested and not tested). Activation patients: The minimum alcohol rates were: SEHC 23.1%, Langdorf 28.2%, combined 24.8%. The minimum illicit drug rates were: SEHC 15.7%, Langdorf 23.5, combined 18.3%. The minimum alcohol and/or illicit drug rates were: SEHC 33.4%, Langdorf 41.8%, combined 36.2%. Nonactivation patients: The SEHC minimum alcohol rate was 4.7% and the minimum illicit drug rate was 6.0%.

Conclusions

Alcohol and illicit drug rates were significantly greater for Trauma Activation Patients, when compared to Nonactivation Patients. At minimum, Trauma Activation Patients are likely to have a 1-in-3 positive test for alcohol and/or an illicit drug. This substantial rate suggests that Trauma Activation Patients, a readily discernible group at trauma center arrival, are appropriate for routine alcohol and illicit drug testing. However, discretionary testing is more reasonable for Trauma Nonactivation Patients, because minimum rates are low.

[Ethical and legal implications of the determination of blood alcohol content in the emergency department]

Alcohol is the most widely consumed toxic in Spain. Excessive alcohol intake is responsible for a significant number of visits to emergency departments (EDs), and what occurs may not only have severe medical consequences, but also serious legal implications. Most Spanish EDs lack specific protocols concerning the correct determination of blood alcohol content (BAC). The present work aims to review the technical, ethical and legal problems surrounding this test. Since ethanol is metabolized in peripheral blood, blood extraction should be standardized in order to preserve the proper chain of custody. An emergency test for BAC should be performed in two scenarios: patients with an altered level of consciousness of unknown origin (when health-care professionals act for the good of the patient), and situations which may be penalized by law (when health-care professionals act for the good of the community). The latter would include traffic controls and traffic accidents, job-related accidents, criminal activities or harmful domestic behaviour. Health-care professionals are responsible for treating patients' clinical information with due respect and confidentiality. However, professional secrecy may be overridden by legal imperative in certain situations. It is necessary to promote conscious ethical decision-taking by the health-care professional, so that this responsibility does not solely depend on the juridical context.

Ethical, legal and policy issues in management of fetal alcohol spectrum disorder

Alcohol use during pregnancy may have severe and lasting effects on the developing fetus. Unfortunately it is often difficult to detect and address maternal drinking, as previous articles in this series have demonstrated. The difficulty is only compounded by a number of ethical quandaries and legal concerns. Underlying most of these concerns is a particularly agonizing conflict of obligations: to protect vulnerable, nascent human life on the one hand, and to preserve the privacy, dignity, and trust of one's patient on the other.

Opioid contracts and random drug testing for people with chronic pain - think twice

The use of opioid contracts, which often require patients to submit to random drug screens, have become widespread amongst physicians using opioids to treat chronic pain. The main purpose of the contract is to improve care through better adherence to opioid therapy but there is little evidence as to its efficacy. The author suggests the use of opioid contracts and random drug testing destroys patients' trust which impacts health outcomes, and that physicians' motivation for their use are concerns about prosecution, medication abuse and misuse, and addiction. Statistics are provided to counter fears, and evidence is offered suggesting opioid contracts are unenforceable and lack efficacy; random drug testing is often inconclusive, and a patient's trust improves adherence to treatment.

Is meconium screening appropriate for universal use? Science and ethics say no

Researchers have been actively looking to biomarker development as a way to improve diagnosis in conditions such as fetal alcohol syndrome (FAS) that have typically been difficult to identify at an early stage. Meconium testing is considered a potentially useful newborn screening method. Screening for alcohol (and other drug) use is unique from all other types of newborn screening in that there is a greater element of social risk for parents, particularly mothers (public exposure of substance use with potential for child welfare involvement). There are many factors related to the science and ethics of the meconium screening process to consider before implementing universal or targeted screening. As care providers who participate in the screening and counseling process and as advocates for infants and their families, neonatal nurses should be active participants in discussions surrounding the ethical and clinical appropriateness of meconium screening program development and expansion. The science behind meconium screening at present is not strong enough to warrant widespread implementation of screening; neonatal nurses are cautioned to approach screening carefully because of the critical social implications for mother and baby.

Testing for drugs of abuse in children and adolescents: addendum--testing in schools and at home

The American Academy of Pediatrics continues to believe that adolescents should not be drug tested without their knowledge and consent. Recent US Supreme Court decisions and market forces have resulted in recommendations for drug testing of adolescents at school and products for parents to use to test adolescents at home. The American Academy of Pediatrics has strong reservations about testing adolescents at school or at home and believes that more research is needed on both safety and efficacy before school-based testing programs are implemented. The American Academy of Pediatrics also believes that more adolescent-specific substance abuse treatment resources are needed to ensure that testing leads to early rehabilitation rather than to punitive measures only.

The Interface: Ethical Decision Making, Medical Toxicology, and Emergency Medicine

The overwhelming social and economic costs of alcohol, tobacco, and other substances of abuse are discussed, as are some of the important public health interventions appropriate for emergency physicians. This article addresses the complexity of ethical decision making when toxicologic emergencies occur in emergency medicine. The management strategies for patients with apparent intoxication are addressed with regard to decision-making capacity. The balance between confidentiality and support for an individual patient and responsibility of the physician to society is discussed. The relative importance of HIPAA is compared with an individual physician's code of ethics.

Ethics of research involving mandatory drug testing of high school athletes in Oregon

There is consensus that children have questionable decisional capacity and, therefore, in general a parent or a guardian must give permission to enroll a child in a research study. Moreover, freedom from duress and coercion, the cardinal rule in research involving adults, is even more important for children. This principle is embodied prominently in the Nuremberg Code (1947) and is embodied in various federal human research protection regulations. In a program named "SATURN" (Student Athletic Testing Using Random Notification), each school in the Oregon public-school system may implement a mandatory drug-testing program for high school student athletes. A prospective study to identify drug use among student-athletes, SATURN is designed both to evaluate the influence of random drug testing and to validate the survey data through identification of individuals who do not report drug use. The enrollment of students in the drug-testing study is a requirement for playing a school sport. In addition to the coercive nature of this study design, there were ethically questionable practices in recruitment, informed consent, and confidentiality. This article concerns the question of whether research can be conducted with high school students in conjunction with a mandatory drug-testing program, while adhering to prevailing ethical standards regarding human-subjects research and specifically the participation of children in research.

[Bioethics and drugs: what is the significance of ethical aspects?]

This philosophical point of view aims at offering a description of some ethical issues arisen from this question. They concern three values: personal freedom and responsibility, public security and benefits for all people, and a correct relationship between each other. An analysis is needed taking into consideration those different approaches, aimed at looking for best solutions: scientific, pragmatic, personal. This study gives moreover a brief account of the Italian bills concerning drug abuse new treatments. The reason for separating ethics issues from the rest of the debate also throws light on the possible synthesis of values, justice and law, as it is contemplated in the Italian Constitution.

Do we have the training? The ethics of workplace drug testing and the GP

BACKGROUND

Workplace drug testing has been in place in Australia since the early 1990s. In some industries it is required by legislation, while in others, employers have introduced it as an apparent cost effective way of improving productivity, safety and the health of its workforce while reducing absenteeism, accident rates and even deaths. There are national standards in place for workplace drug testing regarding specimen collection and testing, and well documented processes to follow in establishing a drug screening program within a workforce.

OBJECTIVE

This article explores the ethics of workplace drug testing and questions the assumed rights and obligations of employer, employee and the clinician involved in occupational medicine.

DISCUSSION

It is questionable whether most general practitioners have the appropriate training to deal with these ethical issues comprehensively.

Keeping lists and naming names: habitual patient files for suspected nontherapeutic drug-seeking patients

Emergency departments commonly keep files of patients who are suspected of frequently visiting them and fabricating symptoms to obtain prescription drugs, usually opioids, for nontherapeutic purposes. Such files have previously been given names such as "frequent flyer file," "repeater log," "kook-book," "problem patient file," "patient alert list," or "special needs file." Little has been written about the ethical, legal, and regulatory considerations that should be taken into account when establishing, maintaining, and using such files. This article explores these issues. The term "habitual patient files" is proposed because it is descriptive without being judgmental.

Urine testing for drugs of abuse: a survey of suburban parent-adolescent dyads

BACKGROUND

The American Academy of Pediatrics is opposed to involuntary diagnostic testing for drugs of abuse.

OBJECTIVE

To gather data about attitudes of parents and their teenagers about involuntary drug testing on parental request.

DESIGN

Adolescents and their accompanying parents separately answered a printed survey in the offices of their private pediatrician. The survey posed 2 hypothetical questions about urine testing: (1) Do parents have the right to ask a teenager's physician to order a urine test for drugs of abuse without the teenager's knowledge-if the teenager has falling school grades, an uncooperative attitude, and major untruthfulness? (2) In such a case, should the teenager's physician obtain a urine test for drugs on parental request only, without the teenager's consent?

RESULTS

A total of 393 paired evaluable surveys were collected: 77.6% from Virginia and 22.4% from Ohio. There were no significant differences in answers between the 2 study sites. Of the students, 85.8% had either an A or a B grade point average. Current marijuana use was unusually low in our teenaged respondents. Of the parents surveyed, 81.7% would want a physician to be able to perform a urine test for drugs of abuse for a problematic teenager without the young person's consent. The answers to the 2 questions about urine drug tests had poor kappa coefficients of agreement between teenagers and parents (0.04 and 0.09, respectively). Reanalysis, using the variables of age, grade point average, and frequency of marijuana smoking, showed little difference in agreement scores.

CONCLUSIONS

In the 2 suburban pediatric practices surveyed, parental opinions and expectations were at variance with the American Academy of Pediatrics policy statement on nonconsensual urine drug testing in the presence of clinical problems. Pediatricians need to be conscious of this clinical-ethical dilemma, become familiar with the American Academy of Pediatrics policy on drug testing, and develop their own position and expertise in this area. The dyad method (parent-teenager survey) is novel and improved the methodology of our study. We surveyed middle-class suburban adolescents while previous studies of adolescents surveyed inner-city populations.