Volume 1, No. 3 • Fall 1986

Current Questions in Patient Safety: Urinary Drug Screening

David E. Leo, M.D.

Question: The hospital administration at our large teaching institution has proposed that all incoming residents be subjected to urinary drug screening tests. What are these, are they legal, and will they help increase patient safety?

Answer: Urinary drug screening is a very contemporary and “hot” issue involving many disciplines ethics, medicine, labor relations, economics and law. Above and beyond alcohol, it is estimated that 5 13% of the American workforce are substance abusers. These figures are paralleled by studies of the medical profession. While constituting only 3.6% of all U.S. physicians, anesthesiologists represent 10 13% of all physicians in drug treatment programs. Recent data ominously suggest that a large number of physicians treated in rehabilitation programs had a long history of drug use, often predating their entry into medicine. Some of the “flower children” of the 60’s have become physicians of the 80’s.

On his most recent hospitalization, President Reagan voluntarily underwent urinary screening to give impetus to the recommendation of his Commission on Organized Crime calling for mandatory testing of all federal employees with security clearances or safety related occupations. Preemployment screening of job applicants for drug use is the most prevalent form of drug testing now in use. It is estimated that more than 30% of all Fortune 500 companies have some sort of drug testing program.

The public generally reacts with ambivalence to drug screening. On the one hand is concern about an Orwellian society with Big Brother overlooking every action. On the other hand, when public saw is involved, opinion strongly supports screening for occupations such as airline pilots, locomotive engineer, public safety officer, air traffic controller, and presumably even physician.

The American Board of Anesthesiology and the American Society of Anesthesiologists both acknowledge the growing problem of substance abuse in recent publications. In the 1986 ABA Booklet of Information the Board has a new policy on chemical dependency (Section 6. 1) and the ASA has recently issued a pamphlet entitled “Questions and Answers About Chemical Dependence and Physician Impairment,” which all anesthesiologists should read. Neither publication, however, addresses the issue of drug screening.

Basically, drug screening pits the employee’s right to privacy against the employer’s attempt to assure quality, avoid liability, and reduce costs. In cases where public safety is involved (including anesthesia) society has an interest in seeing that lives am not in the hands of someone whose judgment is impaired by chemical dependency. Advocates of urinary screening cite successes. Law firms instituting such policies report marked reductions in work-related illness and injury (substance abusers are three times more likely to injure themselves or an innocent third party), absenteeism, and fringe benefit costs (notably health insurance). From an industrial risk management point of view, it is a very cost effective policy.

Opponents argue, however, that urinary drug screening is coercive, is contrary to the tradition of innocent until proven guilty, and violates due process protections when done without just cause. In opposing government-mandated testing, they cite the Fourth Amendment on illegal search and seizure and the Fifth Amendment prohibiting self incrimination. Yet, such arguments do not apply to private employers such as hospitals. Opponents claim the technology is often flawed and subject to false positives and even false negatives. Fentanyl, a drug often chosen by chemically dependent anesthesiologists, cannot be detected by the common urinary screens.

The two most widely used methods of urinary screening are the EMIT system distributed by Syva Co. and the ABUSCREEN System from Roche Diagnostics. Initial claims of 97 99% accuracy have not been supported and confirmatory gas chromatography mass spectrometry (GCMS) is necessary when screens yield positive results. GCMS is 100% accurate for marijuana, cocaine, amphetamines, barbiturates, benzodiazepines, opiates, PCP, methaqualone and methadone, but at considerably greater cost. In all cases, to avoid liability from false incrimination and to maintain legal validity, the screening procedure requires an airtight “chain of evidence custody.” It must be remembered too, that drug testing is only one part of a total approach to reducing chemical dependency and substance abuse in the workplace and does not even address the more prevalent problem of alcoholism. It is an inescapable reality that all hospitals should have a Committee on Physician Health (or some similar title) that deals with detection, treatment and most importantly, prevention.

In summary, urinary drug screening be legal and is winning greater public acceptance especially when administered in a fair, impartial and accurate manner. Screening must be followed by more accurate confirmatory tests before any denial of employment. One major teaching institution in New York City already requires pre-employment urinary screening of all employees including residents; San Francisco, however, has a recently passed ordinance prohibiting random screening without cause. While the legal and ethical issues have not been fully resolved yet, drug abuse screening may serve to protect and, more importantly, reassure the public. At the same time, it will identify colleagues in need of rehabilitation and support before it is too late.

Answer by David E. Leo, M.D., Professor and Chairman, Department of Anesthesia, New York Medical College and Chief, Westchester County Medical Center.