The labs role in developing an institutional drug testing policy

Feb. 1, 2002
Q: I have been asked to represent the laboratory in developing a workplace drug testing policy for our institution. This policy will not only apply to the acute care hospital, but to all outlying clinics and physician practices that the hospital controls. How does the laboratory fit into developing such a policy?A: Its pretty clear that the laboratory is going to play a central role in any drug testing policy, and its a good idea to have laboratorians involved not only in development of the policy, but also in ongoing review and revision. In healthcare workplaces, employers are particularly sensitive to drug and alcohol abusing employees, in part because of the effect an impaired employee can have on patient care, and in part because of the proximity to a supply of drugs in the hospital setting.Federal law regulates to some extent the way in which drug testing policies can be constructed, and state laws will add further refinements. Be certain to have a legal advisor working with you in developing the policy, to insure that no federal or state regulations are violated. The laboratorys role in testing is threefold:to develop appropriate screening tests for each type of testing done;to implement and maintain appropriate chain of custody and testing controls to insure accuracy and confidentiality of test results; andto provide a resource to management when there is a question of interpretation of test results or when there is a suspicion that an employee has tried to beat the test.Developing proper testing methods requires knowing what drugs of abuse will be tested. Most often, drug testing policy includes street drugs such as cannabis and cocaine; in the healthcare setting, it will be particularly important to include medical drugs subject to abuse, such as narcotic pain medications and tranquilizers, as well as alcohol. Just as when a new patient-care test is introduced, the laboratory should investigate the possible testing mechanisms available and select the best one for the circumstances. Particular attention must be paid to the possibility of false results, both positive and negative, and the potential mechanisms of interference. Some thought must also be given to the specimen required: urine is easier to collect than blood, but more subject to tampering and less well correlated with an employees current condition. Hair, saliva, and breath tests are probably not appropriate for institutional use. Confirmation tests for positive results should also be considered to eliminate false positive results at the earliest stage.Once a test method has been determined, either in-house or through a reference laboratory, you should determine, in stepwise fashion, how the sample is to be handled from collection to report, and institute safeguards to insure that specimens are not lost or altered, and that the test sample can be traced from beginning to end. This often means institution of a chain of custody, including signed receipts from each person handling the specimen, similar to that used in criminal cases. A pretest questionnaire for employees, in which they are asked to list drugs they are taking (including herbal supplements, teas, prescription, and over-the counter medications which may contain significant amounts of alcohol as well as other detectible compounds) will be useful in assessing the significance of positive results. Employees handling test specimens and results must understand the sensitive nature of the information and be bound by the highest standards of confidentiality. Violations of confidentiality must be addressed immediately and should have severe repercussions.Almost as important as the lab in the management of drug testing is the Medical Review Officer
(MRO). The MRO is a physician with specialized training in substance abuse and substance abuse testing who can review test results and interview employees to assess both the validity of the test results and the proper course of action. 
The laboratory should also be involved in determining the level at which a test is considered positive (cutoff levels). Different tests may require different cutoffs because of their varying sensitivity. Typically, screening tests have higher cutoffs than do confirmatory tests. The Department of Health and Human Services has established reliable cutoff levels that have the advantage of government sanction. Whenever there is a drug test, there will be employees trying to circumvent it. The laboratory should be prepared to act as a resource to the committee, providing information about avoidance techniques. Perhaps the best role the lab plays in drug testing is to instill confidence in the procedure among the workforce. Despite the concerns of civil libertarians about invasions of privacy because of drug testing, most employees are not threatened by regular drug testing policies, as long as they are professional and they have confidence in the accuracy of the results. Laboratorians can help with the roll out of a new drug policy by explaining the way in which tests are to be performed and safeguards built into the policy to prevent false-positive results from tainting an employees record.Barbara Harty-Golder is a pathologist-attorney in Sarasota, FL. She directs the clinical laboratory at Health South Rehabilitation Hospital in Sarasota, as well as maintaining a law practice with a special interest in medical law. She writes and lectures extensively on healthcare law, risk management, and human resources management.©
2002 Nelson Publishing, Inc. All rights reserved.