Urine Testing's Role in Best Practice
Federal and state guidance is making a strong case for urine testing as an essential component of best-practice models
The addiction treatment field is without question facing some of its most challenging times in light of federal and state budget crises and cutbacks in third-party payment. In response to these issues, treatment providers are being much more heavily questioned about the outcomes of their services. The treatment community is responding by developing best practice protocols within their programs as well as in the field as a whole.
With the shift toward universal healthcare, there is an increasing need to link clinical markers, objective markers and treatment/level of care assessments to drive best practices and to demonstrate successful outcomes. Utilizing urine drug testing and objective markers that demonstrate overall treatment compliance not only regarding abstinence from drugs of abuse but also proper use of prescribed medications is now regarded as an essential component to each individual's treatment protocol.
The American Society of Addiction Medicine (ASAM) and other national organizations are currently defining the paradigm of best practice and are positioning urine drug testing as an essential objective component in the best practice model. ASAM is working to establish guidelines to assist prescribers and other treatment professionals involved in a client's care to ensure routine and ongoing utilization of urine drug testing and monitoring.
While some states are attempting to restrict physicians from ordering necessary urine drug testing for patients, or restricting such tests to substandard instruments, ASAM is leading the debate to allow physicians to order testing as best fits their practice needs and best suits each patient's care. In fact, according to ASAM's 2010 public policy statement on drug testing, “Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and in monitoring of the ongoing status of a person who has been treated for addiction.”
The federal Center for Substance Abuse Treatment (CSAT) within the Substance Abuse and Mental Health Services Administration (SAMHSA) is also a strong advocate of urine drug testing, as explained in its Treatment Improvement Protocol (TIP) 47 titled Substance Abuse: Clinical Issues in Intensive Outpatient Treatment. This monograph provides some detail regarding testing frequencies depending on the stage of treatment and other considerations for outpatient and intensive outpatient programs. Verification of medication management and compliance, abstinence from licit and illicit substances, and monitoring the clearance of such substances are all valuable when implemented and reported properly. Utilization of such tools and the ability to report to funding sources the acuity at intake and the outcomes at discharge are essential to the treatment field.
With the advent of the National Outcome Measures that each state is now required to report to the federal government as part of the block grant process, independent verification of a client's use at intake, improvements during treatment and abstinence at discharge is highly valuable. This will allow treatment programs to demonstrate their effectiveness and be in a better position to advocate continued or increased funding.
To define best practices and help to demonstrate effective outcomes, some states have developed their own best practice guidelines. For example, Vermont developed best practice guidelines for adolescent treatment in 2003. In that document, drug testing is recognized as an objective measure of treatment outcomes within the youth demographic.
Specifically, the Guidelines for the Development of Vermont's Adolescent Treatment System state, “The program should provide or arrange for alcohol and drug testing for all youth diagnosed with substance disorders.” The stated reason for this recommendation: “The process of drug testing is aimed at providing objective measures to support youth, clinicians, parents, and mentors in motivating and sustaining healthy behavior change.”
The key element for Vermont officials was obtaining objective evidence of the efficacy of treatments being provided to youth in order to demonstrate to the legislature and other funding sources their continued fiscal commitment to successful programs.
Comprehensive drug monitoring tools recently have been developed to assist clinicians and programs in demonstrating acuity at intake, treatment progress and outcomes both individually and program-wide. One such tool recently trademarked by Dominion Diagnostics is the Comprehensive Analysis of Reported Drugs (CARD) reporting system. This tool correlates information regarding a client's reported drug use, prescribed medications and non-reported drug use with detected drugs and metabolites within a single report. The clinical data give the clinician, at intake and throughout the course of treatment, quantifiable information regarding each client's progress. Also, this tool can aggregate the data from each client within a program or practice to demonstrate percentages of clients who are compliant with medications prescribed during treatment, who remain abstinent during treatment, etc.
Tools such as CARD can be used to report some of the required National Outcome Measures for programs that receive federal block grant monies, and to report to other third-party payers aggregate data that support the programs' continued insurance participation.
With federal and state mandates to move toward universal healthcare, and other changes anticipated by 2014, treatment centers are well advised to initiate standardized testing instruments within their programs. Organizations that make such changes will be much better positioned to maintain and even increase their revenue sources and client base in this era of health reform.
Peter W. Lee, MA, served as Manager of New Market Development and Government Liaison at Dominion Diagnostics until 2013. He served for 18 years as Chief of Treatment Services and Interim Director at the Vermont Division of Alcohol and Drug Abuse Programs, and has an extensive background in addiction treatment, co-occurring disorders treatment and public administration.