The Hidden Cost of the Opioid Epidemic in the United States: Drug Screening in Insurance Claims

BACKGROUND

The opioid crisis has had a substantial financial impact on the health care system in the United States. This study evaluates how health plans have been affected financially and shows how a laboratory benefit management (LBM) program can be used to address related drug testing in an outpatient setting.

METHODS

Monthly claims data from private health plans were collected from June 1, 2016 to February 29, 2020. The total number of claims (units) for definitive and presumptive drug testing were calculated and the number of paid claims recorded. Claims distribution by laboratory type and medical code billed, the paid rate and compound annual growth rate, and the test distribution and paid rate of rendering providers who had submitted a minimum of 1000 claims were determined.

RESULTS

In total, 2,004,230 drug testing claims were submitted. After the LBM program was implemented, the percentage of paid claims for definitive drug testing (Healthcare Common Procedure Coding System code G0483) decreased and the paid rate for the low-cost tests (HCPCS code G0480) in physician office and independent laboratory settings increased. The compound annual growth rate for G0483 claims submitted indicated a 70.5% and 31.9% decrease in payments to physician offices and independent laboratories, respectively, for the period ending February 2020.

CONCLUSIONS

An LBM program can positively address policy enforcement while reducing unnecessarily complex tests and limiting potential fraud, waste, and abuse by directing testing toward laboratories amenable to cost-efficient contractual savings. Moreover, for definitive drug testing, the enforcement of the use of Healthcare Common Procedure Coding System codes and a move toward more cost-efficient tests (G0480), when clinically applicable, supported by clinical practice guidelines, or evidence-based medicine, is an approach to providing medical benefits while maintaining health costs.

Clinical Benefits of Direct-to-Definitive Testing for Monitoring Compliance in Pain Management

BACKGROUND

The technical advantages of direct-to-definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) urine testing for monitoring patient compliance in pain management are well known. However, the design and implementation of LC-MS/MS methods are more controversial, including factors such as determining appropriate cutoffs, specimen processing (e.g., specimen hydrolysis), reporting of qualitative and/or quantitative results, and test menu.

OBJECTIVES

The objective of the research was to compare the clinical performance of our previous urine pain toxicology panel, a combination of immunoassay (IA) screens and LC-MS/MS, to our current pain toxicology panel, which features direct-to-definitive LC-MS/MS for 34 drugs and metabolites.

STUDY DESIGN

Six months of results from our previous pain toxicology panel were compared to 5.5 months of results from our current pain toxicology panel, enabling us to make conclusions regarding clinical performance.

SETTING

The research took place at Brigham and Women's Hospital in Boston, MA.

METHODS

The percentage of false positive IA results was evaluated for our previous pain toxicology panel. The positivity rates for each drug and/or metabolite were calculated for both the previous and current panels, including rates of detection of both prescribed and illicit drugs. The turnaround time (TAT), direct and send-out costs associated with each approach, as well as projected cost savings were also determined.

RESULTS

False positive rates with IA ranged from 0% to 29%; the highest false positive rate was seen for 6-acetylmorphine (6-AM). The elimination of IA, addition of metabolites, and/or lowering of cutoffs increased the detection rate of 6-AM, benzoylecgonine (cocaine metabolite), fentanyl, morphine, and oxycodone. The ability to differentiate compliance from simulated compliance improved after eliminating specimen hydrolysis. The TAT improved significantly and projected yearly cost savings with the current panel was $95,003 (USD). In our opinion, qualitative results appeared sufficient to assess compliance in the majority of cases.

LIMITATIONS

Our study was performed in a single academic center in a specific geographic region; therefore, our results may not be generalizable to other types of centers or regions.

CONCLUSION

Direct-to-definitive LC-MS/MS testing has several clinical benefits, including reduction of false positive results, improved assessment of patient compliance, decreased TAT, and increased detection of drug use and abuse. Cost savings were also realized using this approach.

KEY WORDS

Direct-to-definitive, LC-MS/MS, immunoassay, sensitivity, cost, pain management, turnaround time, patient compliance.

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.

Comprehensive Urine Drug Screen by Gas Chromatography/Mass Spectrometry (GC/MS)

Drug screening is an essential component of clinical toxicology laboratory service. Some laboratories use only automated chemistry analyzers for limited screening of drugs of abuse and few other drugs. Other laboratories use a combination of various techniques such as immunoassays, colorimetric tests, and mass spectrometry to provide more detailed comprehensive drug screening. Mass spectrometry, gas or liquid, can screen for hundreds of drugs and is often considered the gold standard for comprehensive drug screening. We describe an efficient and rapid gas chromatography/mass spectrometry (GC/MS) method for comprehensive drug screening in urine which utilizes a liquid-liquid extraction, sample concentration, and analysis by GC/MS.

Calculating the social cost of illegal drugs: a theoretical approach

The use of illegal drugs generates a wide range of social harms depending on various ways, according to the policy definition of the problem. The challenge is the way to model the impact of illegal drugs use during a long time period considering the factors that affects the process. Based on these models, estimation could be measured and prediction could be achieved. The illegal drugs use might affect the economic and social structure of the public system leading to direct and effective decisions to overcome the problematic. For that reason, calculation of social cost related to the use of illegal could be introduced over time (t) as a proposed social measure to define the variability of social indicator on society. In this work, a theoretical approach for the calculation of social cost of illegal drugs is proposed and models over time are defined.

[Reimbursement of opiate substitution drugs to militaries in 2007]

INTRODUCTION

The use of psychoactive drugs by militaries is not compatible with the analytical skills and self-control required by their jobs. Military physicians take this problem into consideration by organising systematic drugs screening in the French forces. However, for technical reasons, opiates are not concerned by this screening with the agreement of the people concerned. The estimated number of militaries who use an opiate substitute may be an approach of heroin consumption in the French forces. This study describes buprenorphine and methadone reimbursements made during 2007 by the national military healthcare centre to French militaries.

MATERIAL AND METHOD

Each French soldier is affiliated to a special health insurance. The national military healthcare centre has in its information system, all the data concerning drug reimbursement made to French military personnel. This is a retrospective study of buprenorphine and methadone reimbursements made during 2007 by the military healthcare centre, to militaries from the three sectors of the French forces, and from the gendarmerie and joint forces. Only one reimbursement of one of these two drugs during this period allowed the patient to be included in our study. Daily drug dose and treatment steadiness profile have been calculated according to the criteria of the French monitoring centre for drugs and drug addiction. The criteria of the National guidelines against frauds have been used to identify misuse of these drugs. Doctors' shopping behaviour has also been studied. Finally, the nature of the prescriber and the consumption of other drugs in combination with opiate substitute have been analysed.

RESULTS

One hundred and eighty-one military consumers of opiate substitute drugs (167 men and 14 women) participated. This sample included people from the three sectors of the French forces as well as from the gendarmerie and from the joint forces. The average age of the consumers was 26.6 years (20-42 years). The average length of service was 6.1 years (maximum 22 years service). One hundred and fifty-nine militaries had been delivered buprenorphine, 15 had been delivered methadone and seven had been delivered both. The prevalence of opiate substitute drug consumption by the militaries (52 per 100,000) is lower than in general population. According to the criteria of the National Healthcare Insurance, this population is not affected by abuse or fraud behaviour. Doctors' shopping behaviour is unusual. Opiate substitutes are prescribed by general physicians in 88% of issues. Only one prescriber was a military physician. An analysis of reimbursement of some drugs associated with opiate substitute has been made. The sampled military consume more psychoactive drugs (anxiolytics, antidepressants, hypnotics) than the French population under opiate substitution.

CONCLUSION

In our observation, the military physician is almost always excluded the process of substitution. His/her different responsibilities of care, but also in determining the working aptitude, lead to dissimulation behaviour by the militaries. The difficulty for military physicians is to identify such consumption. They have to evaluate the capacity to work through a physical and psychological examination.

Interpretation of oxycodone concentrations in oral fluid

OBJECTIVE

The purpose of this retrospective study was to compare oxycodone concentrations in saliva and whole blood with a view to propose therapeutic concentrations in oral fluid. Oral fluid is an easy specimen to collect with several advantages over urine, including ease of collection and difficulty of adulteration. As oral fluid is a reflection of free drug circulating in the blood, drug concentrations in saliva are more closely related to blood levels than urine concentrations. The number of testing laboratories offering the analysis of prescription pain medications in urine has increased significantly over the last few years, along with the overuse and abuse of pain killing drugs, specifically oxycodone. Hence, the utility of oral fluid analysis in this field was assessed.

DESIGN

Paired specimens of blood and oral fluid were retrospectively studied in an attempt to establish a range for oxycodone concentrations in oral fluid reflective of therapeutic intake. Twenty-three paired oral fluid-blood specimens were studied. Oral fluid samples had been collected with the Quantisal™ oral fluid device, stored cold and shipped overnight to the laboratory prior to testing. Blood specimens were collected simultaneously in gray top tubes.

RESULTS

From 23 pairs of samples, the median concentration in oral fluid was 524 μg/L and blood was 53 μg/L. The whole blood to plasma ratio for oxycodone was 1.3, so the median plasma concentration was 41 μg/L projecting a saliva to plasma ratio (S:P ratio) of 12. The comparison of oral fluid-blood concentrations allowed the projection of a S:P ratio for oxycodone and the development of a potential therapeutic range for oxycodone in oral fluid.

CONCLUSION

Saliva drug concentrations in pain management are more closely related to blood levels than urine so can be more easily interpreted. These data provide a foundation for interpretative advances; however, further research surrounding other pain medications and controlled studies are necessary.

[Semi-quantitative determination of methadone by TLC]

Methadone is the main therapeutic option in heroin addiction treatment, but also an abuse substance. Given the analytical focus on the diagnosis of drug abuse and the usefulness of toxicological analysis methods in both overdose and monitoring substitution therapy, this study was aimed at the semi-quantitative determination of methadone by using Thin Layer Chromatography (TLC). By having the advantage of simplicity and rapidity, TLC finds its rightful place among the analysis methods when other relatively costly methods that involve instrumental performance are not available.

MATERIALS AND METHODS

TLC plates (silicagel GF 254 Merck), developing system methanol: strong ammonia 100: 1,5, photometric quantification at 254 nm, using TLC Scanner 3 (Camag).

RESULTS

The results show that methadone can be determined semi-quantitatively in the chromatographic conditions mentioned in the two domains tested (5 - 40 microg and 10 - 80 microg), with the best results obtained in the 5 - 40 microg domain.

CONCLUSIONS

Semi-quantitative TLC evaluation proposed by us has as main advantages the rapidity, simplicity and relatively low cost compared to other useful methods.

Urine drug testing in the treatment of chronic noncancer pain in a Kentucky private neuroscience practice: the potential effect of Medicare benefit changes in Kentucky

BACKGROUND

Because the symptoms of drug misuse are nonspecific and difficult to detect, pain physicians have relied heavily on the results of urine drug tests to diagnose and treat chronic noncancer pain in patients who are prescribed controlled substances. However, changes in Medicare local carrier determinations for Medicare Part B providers in Connecticut, Indiana, Kentucky, and New York went into effect on July 1, 2009, whereby qualitative drug screening was no longer recognized as medically reasonable and necessary in the treatment of patients with chronic noncancer pain unless the patient presents with suspected drug overdose.

STUDY DESIGN

A retrospective review of urine drug testing services.

OBJECTIVE

To determine the extent of urine drug testing in patients with chronic noncancer pain in a large, Kentucky neuroscience practice offering pain management services combined with neurologic and neurosurgical services to better understand the potential effects of recent changes to Medicare benefits.

METHODS

An audit of services provided during 2007 was conducted using computer software.

OUTCOME MEASURES

Outcome measures included the number of practice services, number of urine drug tests by payor, and the number of noncompliant patients by payor who self-released from care.

RESULTS

Urine drug tests represented approximately 18.2% of professional medical services rendered in 2007 to patients with a diagnosis of chronic noncancer pain. Of these, UDTs represented approximately 22.2% of services provided to Medicare patients and 24.6% of services provided to Medicaid patients. In 2007, 2,081 patients with noncompliant UDTs self released from the practice against medical advice. Of these, 23.1% were enrolled in Medicare and 47.5% were enrolled in Medicaid. Approximately 40% of patients were referred to the CARE Clinic on the basis of noncompliance as indicated by UDT and/or behavioral health issues. Of these, approximately 50% remained in treatment. Urine drug tests were also instrumental in revealing that 19.6% of patients showed signs of drug abuse or addiction. Of these patients, approximately 60% were government insured.

LIMITATIONS

Not a prospective, double-blinded study. We approximated the proportion of patients potentially affected by drug abuse or addiction as the percentage of patients self releasing from medical care.

CONCLUSION

In 2007, UDTs were used as an effective tool in adherence monitoring in a private neuroscience practice in Kentucky that offers pain management services combined with neurologic and neurosurgical services. UDTs were instrumental in referring 40% of patients for evaluation and treatment by behavioral health and addiction medicine specialists. UDTs were also instrumental in discovering signs of drug abuse or addiction in 19.6% of patients. Of these patients, approximately 60% were government insured. Should the objective and reliable sign offered by UDTs be eliminated from the physician's toolbox, the physician's ability to accurately diagnose and treat these patients could be impaired.

Analysis of the Uniform Accident And Sickness Policy Provision Law: lessons for social work practice, policy, and research

The Uniform Accident and Sickness Policy Provision Law (UPPL) is a state statute that allows insurance companies in 26 states to deny claims for accidents and injuries incurred by persons under the influence of drugs or alcohol. Serious repercussions can result for patients and health care professionals as states enforce this law. To examine differences within the laws that might facilitate amendments or reduce insurance companies' ability to deny claims, a content analysis was carried out of each state's UPPL law. Results showed no meaningful differences between each state's laws. These results indicate patients and health professionals share similar risk related to the UPPL regardless of state.

The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients

OBJECTIVE

To evaluate the cost-effectiveness of using prize-based and voucher-based contingency management (CM) as additions to standard treatment for cocaine- or heroin-dependent outpatients in community treatment centers.

METHODS

This cost-effectiveness analysis is based on a randomized clinical trial conducted at three community-based outpatient psychosocial substance abuse treatment clinics. A total of 142 cocaine- or heroin-dependent outpatients were randomly assigned to one of three treatment conditions: standard treatment (ST), ST with prizes (prize CM), or ST with vouchers (voucher CM) for 12 weeks. The primary patient outcome was the longest duration of confirmed abstinence (LDA) from cocaine, opioids and alcohol during treatment. Unit costs were collected from the three participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Incremental cost-effectiveness ratios (ICERs) and acceptability curves were used to evaluate the relative cost-effectiveness of the interventions.

RESULTS

Based on the ICERs and acceptability curves, ST is likely to be the most cost-effective intervention when the threshold value to decision makers of lengthening the LDA during treatment by 1 week is less than approximately $166, and prize CM is likely to be the most cost-effective intervention when the threshold value is greater than approximately $166.

CONCLUSIONS

Prize CM was found likely to be the most cost-effective intervention over a comparatively wide range of threshold values for lengthening the LDA during treatment by 1 week. However, additional studies with alternative incentive parameters are required to determine the generalizability of our results.

The Finnish legislation on workplace drug testing

In Finland, the Act on the Protection of Privacy in Working Life (759/2004) that entered into force in 2004 incorporates provisions related to drug use testing, e.g. on the employers' right to process in certain situations information on job applicants' and employees' drug use. In the same context, provisions were added to the Occupational Health Care Act (1383/2001) on the employer's obligation to draw up, together with the staff, a written programme dealing with alcohol and drugs for the workplace. The programme defines the overall objectives for and the practices to be observed at the workplace in order to prevent substance abuse and to refer the problem users to treatment. The Occupational Health Care Act also includes provisions on drug tests and the drug test certificate as well as on reimbursement of the expenses of drug tests. Furthermore, the Act lays down a definition of drug tests. Every workplace shall have a plan/programme on drug-free workplace, where the jobs in which the workers have to present a drug test certificate to the employer must be defined. This plan/programme shall be discussed in cooperation on tripartite basis at the workplace. A Government decree on drug use testing (218/2005) has been issued in virtue of the Occupational Health Care Act. It lays down provisions on the practical performance of drug tests, i.e. taking and analysis of samples, and interpretation of the test results. The purpose of the Government decree is to ensure that workplace drug testing is carried out in a way presupposed by a good occupational health care practice and the laboratory quality standards, taking into account the integrity and protection of privacy of the persons tested as well as their other fundamental rights.

Arrested on heroin: a national opportunity

OBJECTIVES

Heroin addiction in the United States exacts significant social, economic, medical, and public health costs, estimated at almost $22 billion in 1996. The national drug control strategy of arrest and mandatory sentencing of drug offenders over the past two decades has resulted in ever greater numbers of drug users who encounter the criminal justice system each year. No estimate of heroin use among the U.S. incarcerated population exists. The authors attempted to estimate the proportion of heroin-using individuals who pass through the corrections system annually to determine the potential impact of interventions designed to link heroin-using individuals to addiction treatment.

METHODS

The authors constructed an estimate by employing the following elements: arrestee drug-testing data, total number of arrests, an estimate of the mean annual number of arrests in a drug-using population, estimates of arrestees incarcerated, and estimates of heroin use and addiction in the U.S. population. The authors present each component of the estimate and how it was derived, and conclude by discussing the degree of uncertainty in the estimates and the implications of our results for policy makers.

RESULTS

Using a conservative estimate, the authors found that 24 percent to 36 percent of all heroin addicts pass through the corrections system each year, representing more than 200,000 individuals.

CONCLUSIONS

Viewed as a public health opportunity, effective linkage to addiction treatment could ultimately reduce the costs associated with poor health, disease transmission, criminality, and recidivism that heroin use exacts on individuals and communities.

The potential for accurately measuring behavioral and economic dimensions of consumption, prices, and markets for illegal drugs

There are numerous analytic and methodological limitations to current measures of drug market activity. This paper explores the structure of markets and individual user behavior to provide an integrated understanding of behavioral and economic (and market) aspects of illegal drug use with an aim toward developing improved procedures for measurement. This involves understanding the social processes that structure illegal distribution networks and drug users' interactions with them. These networks are where and how social behaviors, prices, and markets for illegal drugs intersect. Our focus is upon getting an up close measurement of these activities. Building better measures of consumption behaviors necessitates building better rapport with subjects than typically achieved with one-time surveys in order to overcome withholding and underreporting and to get a comprehensive understanding of the processes involved. This can be achieved through repeated interviews and observations of behaviors. This paper also describes analytic advances that could be adopted to direct this inquiry including behavioral templates, and insights into the economic valuation of labor inputs and cash expenditures for various illegal drugs. Additionally, the paper makes recommendations to funding organizations for developing the mechanisms that would support behavioral scientists to weigh specimens and to collect small samples for laboratory analysis-by providing protection from the potential for arrest. The primary focus is upon U.S. markets. The implications for other countries are discussed.

Effect of the Uniform Accident and Sickness Policy Provision Law on alcohol screening and intervention in trauma centers

BACKGROUND

Alcohol screening and intervention in trauma centers are widely recommended. The Uniform Accident and Sickness Policy Provision Law (UPPL) exists in most states, and allows insurers to refuse payment for treatment of injuries in patients with a positive alcohol or drug test. This article analyzed the UPPL's impact on screening and reimbursement, measured the knowledge of legislators about substance use problems in trauma centers, and determined their opinions about substance use-related exclusions in insurance contracts for trauma care.

METHODS

A nationwide survey of members of the American Association for the Surgery of Trauma was conducted. A separate survey of legislators who are members of the Senate, House, or Assembly and serve in some leadership role on committees responsible for insurance in their state was also performed.

RESULTS

Ninety-eight trauma surgeon and 56 legislator questionnaires were analyzed. Surgeons' familiarity with the UPPL was limited; only 13% believed they practiced in a UPPL state, but 70% actually did. Despite lack of knowledge of the statute, 24% reported an alcohol- or drug-related insurance denial in the past 6 months. This appeared to affect screening practices; the majority of surgeons (51.5%) do not routinely measure blood alcohol concentration, even though over 91% believe blood alcohol concentration testing is important. Most (82%) indicated that if there were no insurance barriers, they would be willing to establish a brief alcohol intervention program in their center. Legislators were aware of the impact of substance use on trauma centers. They overwhelmingly agreed (89%) that alcohol problems are treatable, and 80% believed it is a good idea to offer counseling in trauma centers. As with surgeons, the majority (53%) were not sure whether the UPPL existed in their state, but they favored prohibiting alcohol-related exclusions by a 2:1 ratio, with strong bipartisan support.

CONCLUSIONS

The study documents strong support for screening and intervention programs by both trauma surgeons and legislators. Surgeons experience alcohol-related insurance denials but are not familiar with the state law that sanctions this practice. A majority of legislators are also not familiar with the UPPL but support elimination of insurance statutes that allow exclusion of coverage for trauma care on the basis of intoxication.

Drug testing for multiemployer plans: choosing the proper legal structure

If drug testing of employees in a multiemployer fund must be performed, how should it be funded? This article illustrates the legal issues associated with several entities often used to fund a drug-testing program, such as health and welfare funds, apprenticeship and training funds, and labor-management cooperation committees. Without such a structure, the plan administrator and others could face unnecessary risks.

Urinary screening for methylphenidate (Ritalin) abuse: a comparison of liquid chromatography–tandem mass spectrometry, gas chromatography–mass spectrometry, and immunoassay methods

OBJECTIVE

To develop a routine method for detecting methylphenidate (Ritalin) use among drug abusers using liquid chromatography-tandem mass spectrometry (LC/MS/MS). The new methodology was designed to replace less reliable and/or more expensive and time-consuming techniques (GC/MS and ELISA) currently employed in our laboratory, and to provide a combined one-step screening and confirmation LC/MS/MS method.

DESIGN AND METHODS

Because methylphenidate abuse is very prevalent in Saskatchewan, there is a demand to provide high volume urine screening both to detect abuse, and to monitor compliance. Random urine samples sent for drugs of abuse testing, standards, and controls were diluted 1:100 in methanol. Diluted specimens were injected directly into an Agilent 1100 liquid chromatograph coupled to a Sciex API 2000 mass spectrometer. The method utilized selected reaction monitoring (SRM) as well as an electrospray ionization source (EIS) to detect both urinary methylphenidate and the more prevalent metabolite, ritalinic acid (RA).

RESULTS

There appeared to be little or no sacrifice in sensitivity because the higher dilutions exhibited much less matrix effect. Limit of quantitation (LOQ) for methylphenidate was 100 nM and 500 nM for RA. Linear calibration curves from 100 to 1000 nM for Ritalin and 500 to 5000 nM for RA were acquired. Imprecision of spiked and true specimens did not exceed 10% and at the LOQ, it was less than 20%.

CONCLUSIONS

A rapid, sensitive, reliable, and highly specific method by LC/MS/MS for detecting methylphenidate and its metabolite, RA, were developed. Both the cost and performance of the LC/MS/MS method were superior to GC/MS or ELISA, and it allows use of a single rapid procedure for both screening and confirmation.

Relationships between urinalysis testing for substance use, medical expenditures, and the occurrence of injuries at a large manufacturing firm

Drug use among employees continues to be a serious concern for American employers. Over 80% of the large employers in the United States use some form of testing to detect drug use, but this practice is controversial and the cost-effectiveness of drug testing remains largely unknown. This study begins an empirical investigation of the consequences of drug testing by estimating its impact on medical care expenditures and injury rates at a large manufacturing firm in 1996-1999. Multiple regression analyses of a pooled cross-sectional time-series data set were used to separate the impact of drug testing from other factors and to help find the optimal level of testing that was associated with minimum medical expenditures. Results indicated that medical expenditures would be minimized when 42% of the employees in a calendar quarter were drug tested. This implies that, on average, employees should be tested 1.68 times a year. The results also indicated that doubling the testing rate would reduce the odds of incurring any injuries on the job by over half, but the injury rate was already so low that this impact was very small. Hopefully the results of this study will inform the policy debate over drug testing by focusing on real data, as opposed to supposition or political considerations that seem to dominate many discussions.

Utilization and cost effectiveness of standardized testing for screening and confirmation of drugs of abuse in urine

Screening and confirmation testing for drugs of abuse in urine (DAU) represent areas for potential reduction of laboratory workload and attendant cost savings. Following a careful review of the dinical needs of the underlying veteran patient population served by 7 medical facilities in the Boston area, DAU test ordering frequencies, positive rates for several screening panels and the associated confirmation tests, DAU panel standardization, and confirmation testing only by request were introduced. These changes were all reviewed and approved by the clinician users of DAU testing at each institution before the changes were implemented. Before standardization of DAU screening panels, 59,835 DAU screening requests were done at a cost of $216,005; following standardization, there was 47% decrease in DAU screening utilization (27,876) and costs ($100,633). Before implementation of a DAU confirmation by request only policy, 5,331 confirmation tests were done at a cost of $111,502; after institution of the confirmation policy, there was 95% decrease in confirmation tests (5,080) and costs ($105,826). DAU panel standardization and DAU confirmation by request only have resulted in substantial reductions of laboratory workload and costs in a veterans population and may serve as a model for other patient populations with perhaps similar outcomes.

Measuring outcome in cocaine clinical trials: a comparison of sweat patches with urine toxicology and participant self-report

AIMS

To evaluate the advantages of using a sweat patch (PharmCheck) for detecting cocaine abuse in cocaine-dependent patients participating in a clinical trial. The utility of the sweat patch was assessed from the following perspectives: the reliability and validity of quantitative sweat patch results, the possible degradation of cocaine to benzoylecgonine (BE) as a function of the length of time that a patch is worn, the completeness of the dataset yielded by thrice-weekly urine toxicology compared with thrice-weekly and weekly sweat patches, and the relative costs associated with sweat patch versus urine measures.

DESIGN

Data were collected during a 10-week out-patient clinical trial in which participants wore two sweat patches, one applied every visit and one applied weekly. Urine samples were collected thrice weekly, as were self-reports of substance use.

SETTING

A multi-site clinical trial conducted in Boston, Cincinnati and New York, USA.

PARTICIPANTS

Twenty-seven participants with comorbid diagnoses of cocaine dependence and adult attention deficit disorder completed the study.

MEASUREMENTS

Sweat patch and urine samples were analyzed by standard methods for cocaine and cocaine metabolites.

FINDINGS

Quantitative sweat patch measures had good reliability in that the correlation between the weekly and per-visit patches was 0.96 (P < 0.0001). The concurrent validity, as judged by the correlation between quantitative urine BE levels and either weekly (0.76, P < 0.0001) or per-visit (0.73, P < 0.0001) cocaine sweat patch levels was reasonable. The correlation between the self-report of cocaine use and these same two patches, however, was lower (0.40, P < 0.05 and 0.30, P < 0.05, respectively). The results revealed no significant degradation of cocaine to BE associated with wearing the patch for a longer time. Finally, the per-visit patch provided cocaine use data on 80.5% of all study days (a total of 70), while urine toxicology and the weekly patch provided 77.4% and 76.1%, respectively.

CONCLUSIONS

The present findings suggest that the PharmCheck patch might be an attractive alternative to urine toxicology for use as an outcome measure in cocaine clinical trials.

Rationale and cost-efficiency compared for urine or saliva testing and behavioural inquiry among UK offender populations: injectors, arrestees and prisoners

BACKGROUND

Costs, methodology and efficiency at obtaining behavioural information and biological sample to be tested for blood-borne viruses or illegal drugs are compared for UK surveys of offender populations: injectors in the community or attending drug agencies, arrestees and prisoners.

METHODS

Arrestee surveys use extensive behavioural interview + urine sample and measure a key performance indicator in UK's Drugs Strategy. They have low efficiency (urine sample for drugs testing available from under 60% of eligible arrestees) at high cost (pound sterling 110-190 or 350 per urine sample and at least pound sterling 500-800 per injector). Random mandatory drugs testing of prisoners has the highest efficiency (because refusals are punishable), but the cost is high (pound sterling 110-120 per urine sample and pound sterling 300-500 per injector) and behavioural data are lacking. Prisoner surveys use self-completion questionnaire + saliva sample. They guarantee demonstrable anonymity in estimating the prevalence of blood-borne viruses and prisoners' associated risk behaviours, have high efficiency (saliva sample from over 80% of inmates) at low cost (pound sterling 30 per saliva and pound sterling 70-110 per injector), but behavioural data are limited to risk factors for blood-borne viruses. Low cost also characterises comprehensive interview + saliva sample from injectors in the community (pound sterling 90 per saliva sample, all from injectors) but efficiency cannot be assessed because the sampling frame of eligible injectors is not known. Voluntary unlinked anonymous surveys of injectors at drug agencies use self-completion questionnaire + saliva sample to be tested for blood-borne viruses. They are the least costly at pound sterling 43 per injector and moderately efficient with two-thirds volunteer rate by eligible injectors.

DISCUSSION

For scientific added-value, we recommend co-location of survey types geographically and temporally; a common core set of behavioural questions; saliva sample as well as (and, eventually, instead of) the less acceptable urine sample. Survey methodologies for measuring key performance indicators should stand up to scrutiny in terms of openness, design credentials, statistical power, and costs. We examine how participation bias or inadequate survey size can compromise the effective monitoring of a key performance indicator.

Urine drug screening in the medical setting

BACKGROUND

The term drug screen is a misnomer since it implies screening for all drugs, which is not possible. Current practice is to limit the testing to the examination of serum for several drugs such as ethanol, acetaminophen, salicylate, and of urine for several specific drugs or classes of drugs. In the emergency setting the screen should be performed in less than one hour. Controversies continue to exist regarding the value of urine drug testing in the medical setting. The reasons for these include the drugs involved, the sample, the methods utilized to perform the tests, and the level of understanding of the physician using the data, all of which are closely related to the other.

METHODS

Current automated methods provide rapid results demanded in emergency situations, but are often designed for, or adapted from, workplace testing and are not necessarily optimized for clinical applications. Furthermore, the use of these methods without consideration of the frequency in which the drugs are found in a given area is not cost-effective. The laboratory must understand the limitations of the assays used and provide this information to the physician. Additionally, the laboratory and the physicians using the data must cooperate to determine which drugs are appropriate and necessary to measure for their institution and clinical setting. In doing so it should be remembered that for many drugs, the sample, urine, contains the end product(s) of drug metabolism, not the parent drug. Furthermore, it is necessary to understand the pharmacokinetic parameters of the drug of interest when interpreting data. Finally, while testing for some drugs may not appear cost-effective, the prevention or reduction of morbidity and mortality may offset any laboratory costs.

CONCLUSIONS

While the literature is replete with studies concerning new methods and a few regarding physician understanding, there are none that we could find that thoroughly, objectively, and fully addressed the issues of utility and cost-effectiveness.

The cost of on-site versus off-site workplace urinalysis testing for illicit drug use

Workplace drug testing has become standard business practice in America. With increasing costs, however, many corporations look for more cost-effective testing alternatives. The study compared the cost of two testing strategies: urinalysis at the work site versus testing that occurs elsewhere. Employees from seven company locations were tested for illicit drugs. Four sites conducted the initial screening test at the workplace and three sites performed testing off site. On-site testing was found to have significantly lower variable costs, and total costs were lower once a threshold of 27 employees tested was attained. On-site testing also provided immediate access to negative test results, thereby facilitating personnel decisions.

Innovative technologies for the diagnosis of alcohol abuse and monitoring abstinence

This article summarizes the proceedings of a workshop presented at the 2000 RSA Meeting in Denver, Colorado. The aim of this workshop was to discuss the basic methodologies, diagnostic performance, and clinical utility of three technologies: carbohydrate-deficient transferrin, the "Early Detection of Alcohol Consumption" score, and whole blood associated acetaldehyde. Each method adopts a different strategy to identify heavy alcohol consumption and offers a unique approach to determine alcohol abstinence and relapses. Appropriate application of these technologies can lead to early intervention for alcohol problems before significant tissue damage occurs. To date these methodologies have yet to be formally contrasted and compared. Sensitivity, specificity, predictive value, availability, ease of use, and interpretation of tests results are important aspects to consider when selecting the most appropriate and cost-effective system. Critical evaluation of these methodologies can enable research and clinical laboratories to choose the system that best meets their particular needs in terms of assay feasibility, budget, and goals.

Analysis of urine for drugs of abuse using mixed-mode solid-phase extraction and gas chromatography-mass spectrometry

A method for the simultaneous analysis of urine for the major drugs of abuse is described. The analytical procedure uses solid-phase extraction (SPE), gas chromatography-mass spectrometry (GC-MS) and a semi-automated identification process. It allows simultaneous extraction, derivatization and analysis of acidic, neutral and basic drugs from urine. Urine samples were subjected to enzymatic hydrolysis followed by SPE using Bakerbond narc-2 columns. The eluant was selectively derivatized with N-methyl-bis-trifluoroacetamide (MBTFA) and N-methyl-N-trimethylsilyltrifluoroacetamide + 1% trimethylchlorosilane. Analysis was performed using a GC-MS system operating in full scan mode. A simple macro programme was written to enhance the mass spectra identification capabilities of the MS software by producing extracted ion chromatograms (EIC) for the drugs of interest. Once a suspect compound was indicated by EIC, the mass spectrum of the compound was searched manually against reference libraries for positive identification and the retention time checked against that of the standard. This procedure has increased both the amount and the reliability of information given to clinicians without increasing the cost per sample. The system has been in routine operation for 24 months, processing up to 40 urine samples per day, with a usual turn-around time of 48 h.

Evaluation of the accuracy of on-site multi-analyte drug testing devices in the determination of the prevalence of illicit drugs in drivers

A principal goal of this research was to conduct a field evaluation of "on-site" multi-analyte drug testing devices to determine the most accurate, efficient, and cost-effective device available for the purpose of rapidly detecting drivers under the influence of drugs. Four on-site kits were selected and evaluated for accuracy and efficiency for the detection of tetrahydrocannabinol (THC), the cocaine metabolites (COC), and opiates (OPI). From 16 December 1995 to 17 March 1996, 303 voluntary urine specimens were collected by law enforcement officers from persons arrested for driving-under-the-influence (DUI). These specimens were tested using the four selected kits and aliquots of the specimens were sent to a DHHS certified lab for "gold standard" comparison testing by immunoassay and Gas Chromatography/Mass Spectrometry. On-site kit sensitivity ranged from 82.9% to 100% for THC, 82.5% to 100% for COC, and all were at 100% for OPI. Specificity, and positive and negative predictive values were also determined. Accuracy ranged from 94.0% to 98.3% for THC, 97.4% to 98.0% for COC, and 99.7% to 100% for OPI. All four kits were in very close agreement on prevalence: 15.5% to 15.8% for THC, all were at 13.2% for COC, and all were at 0.7% for OPI. For law enforcement purposes, sensitivity may be the most important indicator in these kits.

Considerations in the interpretation of urine analyses in suspected opiate intoxications

Over the years, it has been observed that in many suspected opiate intoxications, a urine screen using the standard 300 ng/mL cutoff has produced negative results. Subsequent analysis of the blood in many of these cases, in fact, were positive for morphine. To identify the frequency of this occurrence and to determine a more appropriate urine screening cutoff, paired blood and urine specimens were tested for opiates at the above cutoffs. Over the 6 months period of this study, 102 cases were identified where the blood morphine concentration by Roche Abuscreen was greater than 100 ng/mL of "morphine equivalents." All positive cases were confirmed as morphine by gas chromatography-mass spectrometry. Seventy nine of these cases, or 77%, had urine concentrations by Abuscreen exceeding 300 ng/mL of "morphine equivalents." The remaining 23 cases had urine morphine concentrations less than 300 ng/mL by Abuscreen. Urine specimens were then reanalyzed by Abuscreen using dilutions of the 300 ng/mL calibrator: 50, 75, and 150 ng/mL. Even with the use of a 50 ng/mL cutoff, 9 of these 23 specimens tested negative by Abuscreen. Moreover, 23 of the 67 cases or 34% in which the cause of death was narcotic intoxication had urine opiate concentrations by Abuscreen less than the recommended 300 ng/mL cutoff. These results indicate the critical importance in cases of suspected narcotic intoxication of screening the blood in addition to urine.

Alcohol screening and brief intervention: where research meets practice

Numerous studies have consistently shown that quick screening instruments can identify people whose drinking is likely to present health risks and that low-cost, brief interventions are effective in reducing drinking among many such at-risk drinkers. This article describes the results of a one-year policy analysis that explored how alcohol screening and brief intervention (SBI) can be moved to widespread clinical applications in the United States. It introduces the concept of risky drinking and considers the potential of this new technology to reduce it. The research evidence behind this approach is reviewed, and a description of current programs in this and other countries beginning to apply SBI is provided. Economic issues attendant to applications are identified and discussed. The potential for applications in health care is analyzed and summary conclusions from market research are set forth. Recommendations are offered for immediate action.

Cost implications of random mandatory drugs tests in prisons

BACKGROUND

Compulsory urine testing of prisoners for drugs, a control initiative, was introduced in eight prisons in England and Wales early in 1995. Despite no evidence of effectiveness, testing was extended to all prisons in England and Wales by March 1996. We consider the cost of testing.

METHODS

We combined the costs of refusals, confirmatory tests, punishment of confirmed positives for cannabis or for class A drugs to estimate the average costs of random compulsory drugs testing. These costs were then compared to: i) the healthcare budget for a prison; and ii) the cost of putting in place a credible prisons' drugs reduction programme. We then used Scottish data on incarceration and regional prevalence of injecting drug users to estimate the extent of the injecting drug use problem that prisons face.

FINDINGS

Costs per 28 days of the random mandatory drugs testing control initiative in an establishment for 500 inmates where refusal rate is a) 10% or b) nil; and 35% of urine samples test positive, one tenth of them for class A drugs were estimated at between a) 22,800 UK pounds and b) 16,000 UK pounds per 28 days [a) $US35,100 and b) $US24,600]. This cost was equivalent to twice the cost of running a credible drugs reduction and rehabilitation programme, and around half the total healthcare expenditure for a prison of 500 which averaged 41,114 UK pounds per 28 days [$US64,860]. Major cost-generating events were the punishment of refusals--over one third of cost a)--and testing positive for cannabis--over 50% of cost a). In Scotland, around 5% of injecting drug users (IDUs) are incarcerated at any time: 5% of Lothian's drugs care, treatment and prevention costs and 2.5% of its HIV/AIDS prevention budget in 1993-94 amounted to 101,300 UK pounds per annum--or 7770 UK pounds per 28 days ($US11,970)--and about 35% of monthly MDT costs.

INTERPRETATION

We suggest that 5% of current resources for drugs prevention and treatment and for IDU-targetted HIV/AIDS prevention should be directed towards the prisons because in the prisons, where 5% of the clients are at any time, injectors have less access to harm reduction measures than on the outside.

Fostering a drug-free workplace

Drug abuse costs American industry and the public an estimated $100 billion a year. As a result, workplace drug testing programs have become a serious option for many companies. Federal guidelines regarding testing and laboratories are in place. An overview of the current components necessary in designing a corporate drug testing program that complies with these guidelines is presented. Essential features of a corporate workplace drug testing program, that is, the policy, the testing process, and the laboratory contracted to test employees, are detailed from designs suggested in the current literature and in compliance with federal guidelines. Developing a cost-effective corporate program that meets federal guidelines, stands up to court scrutiny, and is universally accepted by employees is the objective of a drug testing program. The challenge can be met by building consensus, spelling out policy, maintaining high testing standards, and above all making rehabilitation of employees who test positive the ultimate goal of a drug-free workforce/workplace.