The biggest issues of toxicology laboratories regarding present-day drug addiction are the current opioid crisis and the growing challenges to counteract this using drug testing. Any provider involved in the treatment and care of patients with addiction should have a clear understanding of what information laboratory drug testing can and cannot deliver.
What are the most important considerations for clinical toxicologists involved in addiction treatment, beyond the regulatory compliance and medical ethics?
1. Proper paperwork
Addiction treatment centers and related programs should have well written procedures for patients and updated information about patient’s drug testing. When making drug testing decisions, clinicians/practitioners should also carefully document their entire procedures and rationale for each patient. Both laboratory professionals and clinicians should keep in mind that there are multiple limitations of drug testing and potential sources of confusion in interpretation of laboratory results, such as: analytical cross reactivity, administration of certain supplements, prescribed medication and attempted adulteration.
2. Privacy and confidentiality
Occasionally, providers are requested to share patient data with outside entities, such as social services agencies or justice system. The expert panel suggests that providers keep the data confidential to the extent permitted by law and follow the compliance when sharing test results (1). Providers should properly take informed consent from patients and keep in mind the hairline difference between objectives and methodology of clinical and forensic toxicology testing. Clinical providers are responsible for offering proper education to patients regarding confidentiality, consent and sharing their results with outside entities (2).
Drug testing for the pain management and addiction treatment requires confirmation with definitive testing via mass spectrometry (LC-MS/MS or GC-MS), although it may be appropriate to share presumptive results especially when they are negative. When sharing presumptive results, laboratorians (e.g. clinical and forensic toxicologists) have to make sure that information is clearly depicted as “presumptive.”
3. Education and knowledge
Accuracy and precision of the drug test depends upon the use of valid testing protocol, which includes pre-analytical, analytical and post-analytical factors. Some of these factors include: sample collection, data analysis and interpretation of results.
The outcome of inappropriate drug testing can have serious consequences for patients. Providers and laboratory professionals have a great responsibility to make sure that they and their team have in-depth knowledge and skills required to provide and maintain high standards drug testing services.
What is the necessary level of expertise towards drug testing services?
Providers who order tests should be aware of the meanings and limitations of clinical toxicology testing, common sources of false positive/negative results, and “tradeoffs” between testing methods. Awareness and familiarity with pros and cons of presumptive screening, importance of cross reactivity in drug testing, validity and integrity of sample, etc. should be strongly considered. Clinicians should also have a good understanding regarding the importance of alternative matrices to urine (e.g. oral fluids, hair, etc.) and the costs of testing methods.
What is the importance of post-analytical process considering knowledge and proficiency?
Interpretation of drug test results is not commonly covered in medical school. Individuals who interpret test results should have good knowledge of clinical toxicology and issues related to proper interpretation. Clinicians and laboratorians involved in drug testing and interpretation of results should attend available courses, and/ or should collaborate with toxicologists or physicians certified as medical review officers (MRO).
What about language and attitude in drug testing services?
The current punchline message is that drug testing should be considered as a therapeutic tool rather than a disciplinary measure. Therefore, applying therapeutic language and a proactive attitude is highly required towards testing and results interpretation and reports. Clinicians and laboratory professionals should always use neutral scientific terminology to avoid aggravation. For example, instead of term “illegal” the term “illicit” could be used, terms “positive” or “negative” instead of “clear” or “messy”, etc. These terms are consistent with a growing body of research literature and clinical guidance regarding “non-stigmatizing language (1, 2)”.
With all these under consideration, drug testing for the addiction treatment requires strong bridging between clinician and testing lab.
One important point to be considered regarding this clinicians-toxicology lab collaboration targets the level of standardization that must exist between testing laboratories. Complicated pharmacokinetics, drug interactions, purity of drugs and analytical methodology differences make difficult the process of standardization between toxicology laboratories and patients are often at high risk due to false positive/negative or misinterpreted results, with severe consequences for those involved in the testing process as well.
Lastly, what are the “quick tips” for toxicology labs in order to provide high standards testing services and achieve clients’ confidence and satisfaction?
- Labs should ensure the expertise level in drug testing for addiction management and treatment by providing professional level services to clinicians and patients;
- Labs should provide the paperwork and certification as per federal/local/state law requirements;
- Labs should ensure compatibility with providers to perform accurate tests;
- Labs should provide technical support for quality and meaningful results interpretations;
- Laboratory staff should establish a collaborative relationship with clinicians; important areas for collaboration are: choice in test panel, validity and integrity of sample testing, test results interpretation and updated literature on trends in drug use.
- Labs should provide the choice of customize and reflex testing, tailored for each patient’s needs.
The “technical staff” of toxicology labs should include: a Medical Director, a Technical Supervisor and at least one Clinical Toxicologist, all readily available to discuss testing panel details, types of drug tests, test procedures and, of course, offer quality technical support.
References:
- Jarvis, M et al. Journal of Addiction Medicine. : p 163–173, May/June 2017.
- https://www.myadlm.org/publications/cln/cln-stat/2017/july/20/drug-testing-in-clinical-addiction-medicine