Counselors’ Clinical Use of Definitive Drug Testin

Authors: Adam Rzetelny Barbara Zeller Nicholas Miller Kathy Egan City Kenneth L Kirsh Steven D Passik

Publish Date: 2015/07/21

Volume: 14, Issue: 1, Pages: 64-80

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Abstract

We conducted a psychotherapeutic examination of the use of definitive drug testing liquid chromatography with tandem mass spectrometry in the treatment of substance use disorders SUD Employing a generic qualitative method Caelli et al in International Journal of Qualitative Methods 22 2003 Merriam 2009 we asked SUD counselors to provide narratives about cases where drug testing had revealed new or unexpected information about clients’ drugtaking behaviors Semistructured interviews with 12 SUD counselors were conducted by phone and analyzed for themes derived from the literature These counselors reported many new positive drug tests in clients previously believed to be adherent with treatment Key themes assessed in counselors’ narratives included initial client denial that was often followed by later acknowledgement of relapse and increased motivation at times presenting new opportunities for clients to engage in treatment and enhance the therapeutic alliance These results suggest that definitive drug testing can be used in a nonstigmatizing and therapeutic mannerDrug testing is an increasingly important component of the treatment of substance use disorders SUD in a variety of settings For example some of the commonly cited purposes of drug testing in the treatment of SUD are listed in the recent American Society of Addiction Medicine White Paper on drug testing ASAM 2013 They include verification of selfreports confirmation of diagnoses identification of denial and minimization of drug and alcohol use enhancement of motivation for treatment measuring biological adaptation assisting in the development of treatment planning monitoring of treatment response documentation of treatment effectiveness and outcomes supporting of client advocacy by validating abstinence from alcohol and drug use and validation of adherence in taking prescribed controlled substances In this view linking drug testing with psychological variables associated with the treatment of SUD such as denial Blume and Marlatt 2009 Levin 1998 and motivation Prochaska et al 1992 suggests a potential psychotherapeutic role of drug testingThis recent reconceptualization of drug testing is striking given its historical roots in a forensic model such as in workplace and criminal justice settings Substance Abuse and Mental Health Services Administration SAMHSA 2012 and as such may carry with it some stigma that should be considered in clinical and therapeutic contexts Reisfield 2014 SAMHSA 2011 In contrast to the forensic use of drug testing with its focus on public safety such as keeping intoxicated truck drivers off the road the goal of clinical drug testing is on improving health outcomes of the patient SAMHSA 2012 Moreover the forensic model relies largely on immunoassay IA technology which while sufficiently suited to its original purpose lacks the sensitivity and specificity of definitive mass spectrometry drug testing Mass spectrometry eg gas chromatography mass spectrometry GCMS or liquid chromatography tandem mass spectrometry LCMS/MS was traditionally used to confirm positive results of IA tests in a sort of twostep process which is why it has been historically referred to as “confirmatory testing” However when medically necessary drug testing can be performed directly with mass spectrometry bypassing the limitations of the IA step Definitive drug testing is more specific and sensitive than IA and is prone to much fewer clinically false negatives and positives Pesce et al 2010 Reisfield et al 2009 Definitive drug testing may be an important tool in clinical settings and in the treatment of SUD ASAM 2013 Gourlay et al 2012 Owen et al 2012Potential obstacles to drug testing have been acknowledged in the literature including concerns of stigmatizing clients burdening the therapeutic relationship or possible legal consequences for clients Reisfield 2014 Gourlay et al 2012 SAMHSA 2011 As SUD are already prone to many sources of stigma Earnshaw et al 2013 any investigation of the potential therapeutic impact of drug testing should include consideration of potential stigma and other obstacles Few studies have examined the clinical impact of drug testing Clancy et al 2013 Reisfield et al 2007 and to our knowledge none have specifically investigated the potential psychotherapeutic role of drug testing in the treatment of SUD Thus the focus of this paper is to address this need through a genericqualitative Caelli et al 2003 Merriam 2009 examination of how drug testing may impact treatment at the individual level from the point of view of counselors’ work with their clients The purpose of this study has two components The first is to provide some insights from SUD counselors through our own psychotherapeutic lens to other counselors who are or are considering integrating clinical drug testing into their work with clients The second purpose is to provide preliminary data to help generate hypotheses for future studies as part of a progression toward further developing this line of inquiryIt should be noted that in many states counselors are not authorized to independently order clinical laboratory tests including drug testing But members of a clinical team can use a baseline understanding of drug testing to help understand this objective data about their clients Learning how to understand drug test results may create an opportunity for use in therapy efforts with clients/patientsWe are getting a lot more positive results right now which everybody is sort of reeling from It’s been very disruptive it’s difficult but I think it’s really important because otherwise how do we know what are we actually doing So I definitely think it’s a pro You know the con is obviously the learning curve because we are switching from something that was sort of permissive so now everyone has to adjustThere seemed to be a growing realization that the community might have to reevaluate their culture and how they deal with denial and that there was much work remaining in order to help clients achieve their goals of sobriety In fact part of the impetus for this study was the spontaneous and passionate revelations from many counselors about how their understanding of their clients and their work with them had changed in the face of the new drug testing that provided more specific clinical data They wanted to get their stories out and share them with the rest of the SUDtreatment world

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