Can Big Rig Drivers Beat Drug Tests?
By Robert Arnold
POSTED: 10:03 am CST December 20, 2007
UPDATED: 12:46 pm CST December 22, 2007
HOUSTON -- Local 2 investigates potentially dangerous loopholes in federal drug testing laws. Our hidden cameras expose a flawed system that can allow drug addicts to get behind the wheel of an 18-wheeler or even a school bus. Local 2 investigative reporter Robert Arnold shows us how what we uncovered now has Congress and the industry demanding change.
We sent our hidden cameras to a Houston drug testing facility where we signed up to take an official Department of Transportation drug test. Federal law requires every driver to get a drug test before they're allowed to drive an 18-wheeler, a school bus or any kind of commercial vehicle.
But before Local 2 went for the test, we were able to order drug-free urine off the Internet.
The kit Local 2 purchased came with a tube of dehydrated urine, a vial and a small heater. We mixed the powdered urine with water then used the heater to bring the sample up to the temperature of the human body.
At the collection facility, Arnold was ordered to take off his sport coat and place the contents of his pockets in a secure locker. That was the extent of the search, which meant no one at the facility knew Arnold had the vial of mail-order urine hidden as he entered the bathroom.
Once inside the bathroom, Arnold was allowed to close and lock the door, which allowed him to use the vial of mail-order urine as his sample for the drug test.
Arnold was then sent to a bathroom to provide a urine specimen for drug test.
A few days later the results of Arnold's drug test came back negative. The mail-order urine passed with no problems at all.
The facility Local 2 tested did absolutely nothing wrong. Employees followed every procedure they are required to follow when collecting a specimen for a Department of Transportation drug test. Yet, Local 2 still found it easy to beat the test.
"Your investigation shows how easy it is to circumvent the law," said U.S. Rep. Ted Poe, who sits on Congress' Transportation Committee.
"Those regulations were written based on the premise that the person giving the sample was going to be honest about it," said Poe. "That's not the world we live in."
Poe said what concerns him is if Arnold had been a drug user, then that negative test would still allow him to drive an 18-wheeler, a school bus or any kind of commercial vehicle.
"When it's so easy to circumvent the law, the law becomes meaningless," said Poe.
"Whatever needs to be done to tighten the regulations to ensure that we don't have anyone slip through the cracks like you did, then I think that needs to be addressed," said Van O'Neal, the head of Houston Community College's truck driving school.
O'Neal's program is one of the largest in the country and requires 50 percent of students and faculty to undergo random drug tests. He says that's why Congress has to tighten the regulations.
"Those policies must be followed, not need to be followed, but I believe must be followed to ensure that our roadways are safe," O'Neal said.
Congress is promising to come up with tougher regulations because what Local 2 did was not an isolated case. A report from the Government Accountability Office shows federal investigators also circumvented drug testing laws at several facilities. The report even warns Congress it impossible to determine how many drivers have been able to beat the federally required drug test.
Federal law also requires trucking companies to randomly test employees to hopefully catch those who may have beat the test the first time. But after Local 2 Investigates combed through tens of thousands of federal violations, we found not everyone is following the law.
Monday, December 24, 2007
Wednesday, December 5, 2007
Oxycodone & Hydrocodone Abuse Deaths Exceed Heroin
Tampa, Florida -
Drug related deaths for oxycodone and hydrocondone exceed those for heroin in the State of Florida.
U.S. Drug Czar John Walters again voiced concern about the abuse of prescription drugs.Walters, National Director of Drugs Control Policy, noted that many teens and young people believe prescription pills are not as dangerous as street drugs.
12% of people between the ages of 18 and 25 report abusing prescription drugs in the past year.
CBS NEWS - WTSP - Tampa Bay's 10 News - Tampa / St. Petersburg
Drug related deaths for oxycodone and hydrocondone exceed those for heroin in the State of Florida.
U.S. Drug Czar John Walters again voiced concern about the abuse of prescription drugs.Walters, National Director of Drugs Control Policy, noted that many teens and young people believe prescription pills are not as dangerous as street drugs.
12% of people between the ages of 18 and 25 report abusing prescription drugs in the past year.
CBS NEWS - WTSP - Tampa Bay's 10 News - Tampa / St. Petersburg
Tuesday, November 6, 2007
DOT Drug Testing Ineffective - GAO Government Report
Now even the US Government knows the obvious ....
Drug testing without observed specimen collection, is a waste of time and money.
Private interest groups, consisting largely of urine drug testing laboratories, urine-centric TPA's & occupational health clinics, some unions, as well as some archaic government bureaucracies (DOT, FAA, etc.) continue to exclusively support urine-based testing vs. superior, user-friendly technologies - most notably oral fluid / saliva and hair-based drug screening.
Oral fluid / saliva and hair-based drug screening technologies allow for observed specimen collection and are relatively non-invasive vs. traditional urine drug testing.
Oral fluid delivers information on "current" / "on-the-job" drug and/or alcohol use, while hair detects "historical drug abuse".
Oral fluid / saliva is suitable for random, post-accident, and reasonable suspicion testing, and also can be used for pre-employment testing.
Hair is most appropriate for pre-employment testing, especially for employers that wish to track drug use history for a period of up to 90 days.
The DOT and other government agencies, including "regulatory agencies" such as SAMHSA are largely to blame for the continued emphasis upon traditional urine-based testing, as ultimately serving to help perpetuate America's problem with substance abuse.
Government agencies resist moving to newer technologies either due to the fear of having to "do more work", and/or are impacted by private interest groups with heavy lobbying budgets and well established "old boy networks".
The DOT claims "success" by noting a "2% positive rate". This is a blatant misuse of statistics. Of course the is only a 2% positive rate... as most drug abusers are cheating the test!
As noted below, if drug testing involved observed specimen collection, and/or more stringent techniques the positive rate soars to 10%.
Urine-based drug testing is simply:
1. too difficult, costly, and noxious to apply consistently and on a corporate-wide / industry-wide basis,
2. prone to drug abusers "beating the test".
Several documented cases support the above facts:
For example, a recent construction site that had a low "positive rate" using tradition urine drug testing, but had several site issues and eventually discovered hypodermic needles on-site.
When they implemented Avitar's oral fluid-based testing, conducing a full site-based random screen, the positive rate registered 20%!
Urine testing laboratories, in most cases, are not able to determine if urine samples are adulterated or substituted, other than in the most basic and severe cases.
Despite this fact, they continue to spread misinformation, claiming the opposite.
The Director of Workplace Drug Testing for SAMHSA is on record, testifying before Congress, that detect adulterants, that labs can only detect a very small fraction of the many products available on the Internet available to beat urine-based drug tests, and that substituted drug free urine and synthetic urine also are undetectable.
GAO: Easy to cheat on trucker drug tests
Three-quarters of testing sites don’t provide secure conditions, report finds
The Transportation Department estimates that fewer than 2 percent of truck drivers test positive each year for controlled substances. But when Oregon conducted its own tests, 9 percent of truck drivers tested positive. Dozens of products on the Web are marketed to truckers as fail-safe ways to defeat the mandatory drug tests.
WASHINGTON - Undercover federal investigators discovered that it was surprisingly easy to cheat on random drug tests designed to catch truck drivers who use drugs, NBC News has learned.
Undercover investigators with the Government Accountability Office (GAO), the investigative arm of Congress, used bogus truck driver’s licenses to gain access to 24 drug-testing sites.
They found that 75 percent “failed to restrict access to items that could be used to adulterate or dilute the [urine] specimen, meaning that running water, soap, or air freshener was available in the bathroom during the test.”
The GAO team also bought drug-masking products over the Web and was able to mix them with real specimens at the drug-testing sites “without being caught by site collectors,” the agency said in a report scheduled to be made public Thursday
Drug-screening labs never realized that there was a problem. “Every drug masking product went undetected by the drug screening labs,” said the report, a copy of which was obtained by NBC News.
Rep. Jim Oberstar, D-Minn., chairman of the House Transportation and Infrastructure Committee, said the report was “frankly astonishing and shocking and dismaying. You can manipulate the tests, you can mask substance abuse and go undetected on the roadways.”
Oberstar, who planned to hold a hearing Thursday, said the drug-testing system was broken and was placing other drivers in danger.
“It fails, it is not sufficient, it is not protecting the public interest,” he said.
How many are cheating?The Transportation Department estimates that fewer than 2 percent of truck drivers test positive each year for controlled substances in random federal tests. But when Oregon law enforcement officials conducted their own random tests this year, 9 percent of truck drivers tested positive.
Dozens of products widely available on the Web are marketed to truckers as fail-safe ways to defeat the mandatory drug tests.
“My first reaction was total disbelief. I just felt sick,” said Kathleen Ellsbury, whose husband, Tony Qamar, was killed two years ago when a truck driver in Washington state lost his load of logs on a curve, crushing Qamar’s car. Also killed was Daniel Johnson, a fellow seismologist at the University of Washington.
Ellsbury learned later that the truck driver, who was sentenced to 4½ years in prison for vehicular homicide, had previously been convicted of possessing methamphetamines and that he had meth in his blood at the time of the crash.
“The system has big holes, let’s say that,” said Ellsbury, who said she had a message for truck drivers who might be tempted to cheat:
“I’d like to be standing right outside the bathroom and hold up a picture of my husband — remind them there's consequences.”
Truckers promise to do betterSpokesmen for the trucking industry said truck drivers were among the safest drivers on the road, with much lower rates of drug use than the general population. Still, they said, having roughly 30,000 drivers test positive each year was unacceptable.
Lisa Myers is chief investigative correspondent and Richard Gardella is an investigative producer for NBC.
Drug testing without observed specimen collection, is a waste of time and money.
Private interest groups, consisting largely of urine drug testing laboratories, urine-centric TPA's & occupational health clinics, some unions, as well as some archaic government bureaucracies (DOT, FAA, etc.) continue to exclusively support urine-based testing vs. superior, user-friendly technologies - most notably oral fluid / saliva and hair-based drug screening.
Oral fluid / saliva and hair-based drug screening technologies allow for observed specimen collection and are relatively non-invasive vs. traditional urine drug testing.
Oral fluid delivers information on "current" / "on-the-job" drug and/or alcohol use, while hair detects "historical drug abuse".
Oral fluid / saliva is suitable for random, post-accident, and reasonable suspicion testing, and also can be used for pre-employment testing.
Hair is most appropriate for pre-employment testing, especially for employers that wish to track drug use history for a period of up to 90 days.
The DOT and other government agencies, including "regulatory agencies" such as SAMHSA are largely to blame for the continued emphasis upon traditional urine-based testing, as ultimately serving to help perpetuate America's problem with substance abuse.
Government agencies resist moving to newer technologies either due to the fear of having to "do more work", and/or are impacted by private interest groups with heavy lobbying budgets and well established "old boy networks".
The DOT claims "success" by noting a "2% positive rate". This is a blatant misuse of statistics. Of course the is only a 2% positive rate... as most drug abusers are cheating the test!
As noted below, if drug testing involved observed specimen collection, and/or more stringent techniques the positive rate soars to 10%.
Urine-based drug testing is simply:
1. too difficult, costly, and noxious to apply consistently and on a corporate-wide / industry-wide basis,
2. prone to drug abusers "beating the test".
Several documented cases support the above facts:
For example, a recent construction site that had a low "positive rate" using tradition urine drug testing, but had several site issues and eventually discovered hypodermic needles on-site.
When they implemented Avitar's oral fluid-based testing, conducing a full site-based random screen, the positive rate registered 20%!
Urine testing laboratories, in most cases, are not able to determine if urine samples are adulterated or substituted, other than in the most basic and severe cases.
Despite this fact, they continue to spread misinformation, claiming the opposite.
The Director of Workplace Drug Testing for SAMHSA is on record, testifying before Congress, that detect adulterants, that labs can only detect a very small fraction of the many products available on the Internet available to beat urine-based drug tests, and that substituted drug free urine and synthetic urine also are undetectable.
GAO: Easy to cheat on trucker drug tests
Three-quarters of testing sites don’t provide secure conditions, report finds
The Transportation Department estimates that fewer than 2 percent of truck drivers test positive each year for controlled substances. But when Oregon conducted its own tests, 9 percent of truck drivers tested positive. Dozens of products on the Web are marketed to truckers as fail-safe ways to defeat the mandatory drug tests.
WASHINGTON - Undercover federal investigators discovered that it was surprisingly easy to cheat on random drug tests designed to catch truck drivers who use drugs, NBC News has learned.
Undercover investigators with the Government Accountability Office (GAO), the investigative arm of Congress, used bogus truck driver’s licenses to gain access to 24 drug-testing sites.
They found that 75 percent “failed to restrict access to items that could be used to adulterate or dilute the [urine] specimen, meaning that running water, soap, or air freshener was available in the bathroom during the test.”
The GAO team also bought drug-masking products over the Web and was able to mix them with real specimens at the drug-testing sites “without being caught by site collectors,” the agency said in a report scheduled to be made public Thursday
Drug-screening labs never realized that there was a problem. “Every drug masking product went undetected by the drug screening labs,” said the report, a copy of which was obtained by NBC News.
Rep. Jim Oberstar, D-Minn., chairman of the House Transportation and Infrastructure Committee, said the report was “frankly astonishing and shocking and dismaying. You can manipulate the tests, you can mask substance abuse and go undetected on the roadways.”
Oberstar, who planned to hold a hearing Thursday, said the drug-testing system was broken and was placing other drivers in danger.
“It fails, it is not sufficient, it is not protecting the public interest,” he said.
How many are cheating?The Transportation Department estimates that fewer than 2 percent of truck drivers test positive each year for controlled substances in random federal tests. But when Oregon law enforcement officials conducted their own random tests this year, 9 percent of truck drivers tested positive.
Dozens of products widely available on the Web are marketed to truckers as fail-safe ways to defeat the mandatory drug tests.
“My first reaction was total disbelief. I just felt sick,” said Kathleen Ellsbury, whose husband, Tony Qamar, was killed two years ago when a truck driver in Washington state lost his load of logs on a curve, crushing Qamar’s car. Also killed was Daniel Johnson, a fellow seismologist at the University of Washington.
Ellsbury learned later that the truck driver, who was sentenced to 4½ years in prison for vehicular homicide, had previously been convicted of possessing methamphetamines and that he had meth in his blood at the time of the crash.
“The system has big holes, let’s say that,” said Ellsbury, who said she had a message for truck drivers who might be tempted to cheat:
“I’d like to be standing right outside the bathroom and hold up a picture of my husband — remind them there's consequences.”
Truckers promise to do betterSpokesmen for the trucking industry said truck drivers were among the safest drivers on the road, with much lower rates of drug use than the general population. Still, they said, having roughly 30,000 drivers test positive each year was unacceptable.
Lisa Myers is chief investigative correspondent and Richard Gardella is an investigative producer for NBC.
Friday, October 5, 2007
" New " Building Contruction Trades Department Drug Testing Program - A Costly Mistake
For Safety Professionals attempting to innovate and improve efforts can be frustrating, largel due to the fact that politics can easily supersede logic.
That said, while potentially well-intentioned, the "new" Building and Construction Trades Department - BCTD drug testing program ( which oddly requires outdated and relatively ineffective urine-based testing as well as the use of a specific laboratory, third party administrator, and their specific product and services ) represents a step backwards...not forward ....
more importantly, however, this archaic structure does NOT serve the best interests of unions, union members, contractors, insurers, or owners.
The Need for Change: Substance Abuse in the Construction Sector
We all know that a drug free workplace is a safe workplace and the union skilled trades and contractors were ahead of their time years 16 years ago, when urine-based drug testing was introduce by innovators as evidence by the MUST program, LEAD, and others.
However, times change, the drugs of choice change and the numbers of ways to “beat” the tests have changed.
It’s time again for the union skilled trades and contractors to leap ahead of the national status quo.
Recently the States of Hawaii and Georgia passed legislation to improve safety and reduce workers compensation costs through the implementation of on-site oral fluid / saliva drug screening.
The construction industry played a key role in driving these changes, especially in Hawaii. Organized labor in particular, as well as contractors, owners, and insurers recognized the following:
Drug abuse in the construction sector is as bad, if not worse than ever,
Effective drug testing, especially random drug testing is required to truly manage workplace substance abuse,
Observed specimen collection, convenience, and low cost are mandatory to ensure compliance.
It's time again for union's to put politics aside and address the issue from from a safety point of view.
Why drug test?Simple. While 10% of employees aged 18 – 49 years abuse drugs (not including alcohol), the construction industry runs 2x-3x this rate.
With over 50% of reportable job-site accidents linked to substance abuse, it’s clear that employee safety and the corporate bottom line are sufficient reasons to implement a drug free workplace program.
Pre-employment drug testing has become an intelligence test. Access to the internet has made defeating drug tests an easy task. Workers are able to get information on how to “flush” their system; adulterate samples; and there are even products like the Whizinator, which uses synthetic urine undetectable by current drug testing methods, designed to defeat observed urine collection.
Random drug testing, post-incident and reasonable suspicion modes are required components of any comprehensive, effective safety program. The goal of any drug / alcohol policy is deterrence vs. “catching” employees. Random testing has consistently demonstrated to be singularly effective in reducing on-the-job substance abuse.
Any effective testing mode must involve direct observation of specimen collection.
But observed urine collection is embarrassing and degrading to both the observed and the observer.Arguably, there are more instances of drug abusers defeating unobserved techniques, such as traditional urine-based testing, than there are “positives”. Just look at nationwide statistics for validation. Seventy-seven percent (77%) of drug abusers are employed. Furthermore most drug testing (approx. 90%) involves traditional urine laboratory-based pre-employment testing.
Oral fluid works . Oral fluid tests are cheaper, faster and easier to use than urinalysis… and unlike urine, can not be easily defeated.Random testing via on-site oral fluid is fast, provides results within 5-15 minutes, and averages $20 per test.
It has the additional advantage of detecting current, vs. historical drug use. Oral fluid tests typically detect from within minutes of consumption up to 2-3 days for most drugs (for THC, the psychoactive ingredient in marijuana, the maximum is 24 hours.). Urine testing can not detect drugs for up to the first several hours and is only an indicator of historical drug use. Furthermore, for THC, detection can go back as far as 30 days.
Do you as an employer really care what an otherwise dependable employee does at his/her home on the weekend?
Do you even have a right to know?
“This measure (on-site oral fluid drug testing) provides a cost effective on-the-job alternative to laboratory tests that can be costly and difficult to schedule."- Aiona, Lt. Governor, Hawaii
Also look at the true costs of urine-based random testing.
In many cases current programs require we send our employees off site for random testing. The cost involved includes not only the hourly labor rate, probably $50/hour with benefits, but the productivity loss also. The end result is that a typical off-site urine test is truly costing a job about $300 per test, and the effectiveness is questionable at best.
On-site oral fluid based testing works. Here are actual results from a contractor who switched from urine-based to oral fluid-based drug screening:
Where do we go from here?
Occupational health, safety, and risk management professionals must assist in driving change. This groups and only this group knows what truly happens every day on our job sites.
At the end of day, they “get it”.
It’s time for safety professionals to join with all constituencies to update current drug and alcohol free workplace programs to assure, no ... demand, compliance and effectiveness.
It’s also time for the union skilled trades and contractors to again lead the charge in effecting change.
It’s time to implement oral fluid-based testing techniques at a few “pilot sites” and demonstrate the advantage of effective drug testing programs vs. the status quo.
References:2006 United States Department of Health – Substance Abuse and Mental Health Agency (SAMSHA) National Survey on Drug Use & Health (NHSDA)- Office of Applied Studies. (2007) Results from the 2006 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 07-4293, NSDUH Series H-32). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Peter N. Cholakis and Roger Bruce (July 2007) Drug Testing in the Workplace – A look at oral fluid-based testing. Professional Safety Journal of the American Society of Safety Engineers, July 2007, 31-36
Tuesday, October 2, 2007
New Government (SAMHSA) Study Shows Value of Workplace Drug Testing
2007 " Worker Substance Use and Workplace Policies and Programs "
Substance Abuse and Mental Health Services Agency (SAMHSA)
United States Department of Health and Human Services
If your workforce includes employees between the ages of 18 and 34 years old, and you do not have a comprehensive drug free workplace program, there is a good chance that you have substance abusers on the payroll.
A new federal study indicates that 19% of workers in that age group are current (in the previous 30 days) illicit drug users ...
... compared with 10.3% of those between 26 and 34,
... and, 7% of those between 35 and 49,
... and 2.6% of workers between 50 and 64.
The report, using data collected during 2002, 2003, and 2004, makes it possible to anticipate substance abuse issues within a variety of demographic categories.
If your company hires and has existing employees of these demographics, then you should conduct drug testing, especially random drug testing.
Highest Substance Abuse Industries / Occupations:
Percent of Full-Time Workers Currently Abusing Drug (ages 18-64)
18% "Food Services and Drinking Places"
16% "Performing Arts, Spectator, and Related Industries"
15% "General Merchandise Stores"
14% "Construction"
14% "Landscaping"
Importanc of Drug-Free Workplace Programs
Unfortunately, however, few relatively few companies drug test:
The study contains information about drug-free workplace program trends. While approximately 44% of workers report availability of drug an alcohol educational information, 58% of employers offer an employee assistance programs, and 79% indicate of employers have a written drug-free workplace policy, less than half ( 42.9% ) of full-time workers reported that their employers conduct pre-employment testing, and only 29.6% reported ANY form of random testing programs where they work.
Substance Abuse and Mental Health Services Agency (SAMHSA)
United States Department of Health and Human Services
If your workforce includes employees between the ages of 18 and 34 years old, and you do not have a comprehensive drug free workplace program, there is a good chance that you have substance abusers on the payroll.
A new federal study indicates that 19% of workers in that age group are current (in the previous 30 days) illicit drug users ...
... compared with 10.3% of those between 26 and 34,
... and, 7% of those between 35 and 49,
... and 2.6% of workers between 50 and 64.
The report, using data collected during 2002, 2003, and 2004, makes it possible to anticipate substance abuse issues within a variety of demographic categories.
If your company hires and has existing employees of these demographics, then you should conduct drug testing, especially random drug testing.
Highest Substance Abuse Industries / Occupations:
Percent of Full-Time Workers Currently Abusing Drug (ages 18-64)
18% "Food Services and Drinking Places"
16% "Performing Arts, Spectator, and Related Industries"
15% "General Merchandise Stores"
14% "Construction"
14% "Landscaping"
Importanc of Drug-Free Workplace Programs
Unfortunately, however, few relatively few companies drug test:
The study contains information about drug-free workplace program trends. While approximately 44% of workers report availability of drug an alcohol educational information, 58% of employers offer an employee assistance programs, and 79% indicate of employers have a written drug-free workplace policy, less than half ( 42.9% ) of full-time workers reported that their employers conduct pre-employment testing, and only 29.6% reported ANY form of random testing programs where they work.
Opioid Treatment - Glossary
Glossary
-A-
abstinence
Nonuse of alcohol or any illicit drugs, as well as nonabuse of medications normally obtained by prescription or over the counter.
acute phase
Initial and usually the most symptomatic intensive-treatment phase
addiction
Combination of the physical dependence on, behavioral manifestations of the use of, and subjective sense of need and craving for a psychoactive substance, leading to compulsive use of the substance either for its positive effects or to avoid negative effects associated with abstinence from that substance. Compare dependence.
administrative discharge
Release or discharge of a patient from an OTP, often against the patient's wishes. See involuntary discharge. admission. Formal process of enrolling patients in an OTP, carried out by qualified personnel who determine that the patient meets acceptable medical criteria for treatment. Admission can include orientation to the program and an introduction to peer support, patient rights, services, rules, and treatment requirements related to MAT.
agonist. See opioid agonist.
analgesic
A compound that alleviates pain without causing loss of consciousness. Opioid analgesics are a class of compounds that bind to specific receptors in the central nervous system to block the perception of pain or affect the emotional response to pain. Such compounds include opium and its derivatives, as well as a number of synthetic compounds. Chronic administration or abuse of opioid analgesics may lead to addiction.
antagonist. See opioid antagonist.
assessment
Process of identifying the precise nature and extent of a patient's substance use disorder and other medical, mental health, and social problems as a basis for treatment planning. Assessment usually begins during program admission and continues throughout treatment. It includes a personal substance abuse history, physical examination, laboratory evaluation, and determination of disease morbidity. Severity of disease often is assessed further in terms of physiologic dependence, organ system damage, and psychosocial morbidity. Assessment also may involve determining patient motivation and readiness for change.
assessment tools
Instruments (e.g., questionnaires) used to capture the range of patient variables affecting treatment planning, methods, and outcomes. Valid assessment tools contain quantifiable indicators to measure patient progress and to track patients through treatment.
Axis I. DSM-IV-TR disorder classification comprising definitions and descriptions of major disorders (i.e., psychotic, mood, and substance use disorders) that may require clinical attention.
-B-
benzodiazepines
Group of medications having a common molecular structure and similar pharmacological activity, including antianxiety, sedative, hypnotic, amnestic, anticonvulsant, and muscle-relaxing effects. Benzodiazepines are among the most widely prescribed medications (e.g., diazepam, chlordiazepoxide, clonazepam, alprazolam, lorazepam).
best-treatment practices. Methods determined, often by a consensus of experts, to be optimal for defined therapeutic situations. Such guidelines usually are based on both an analysis of published research findings and the experience of experts.
blood testing
Identifying evidence of opioid and other psychoactive substance use and measuring the levels of substances or medications in the body by examining patient blood specimens for the presence and concentrations of identifiable drugs and their metabolites.
buprenorphine
Partial opioid agonist approved by FDA for use in detoxification or maintenance treatment of opioid addiction and marketed under the trade names Subutex® and Suboxone® (the latter also containing naloxone).
-C-
civil commitment
Legal process that permits individuals to be confined against their will in psychiatric or other treatment facilities, which usually is justified by determining that a patient is a threat to himself or herself or others. Although statutes permitting involuntary civil commitment may remain in some States, such laws rarely have been used to commit people who abuse substances and are not under criminal justice jurisdiction.
Commission on Accreditation of Rehabilitation Facilities (CARF)
One of several SAMHSA-approved accreditation organizations charged with ensuring that OTPs meet the standards set forth in Federal regulations and SAMHSA guidelines. Also known as CARF… The Rehabilitation Accreditation Commission.
comprehensive maintenance treatment
Continuous therapy with medication in conjunction with a wide range of medical, psychiatric, and psychosocial services. Compare medical maintenance.
comprehensive treatment assessment
Evaluation made after formal admission to an OTP, in which trained staff members determine the range and severity of a patient's problems and the patient's service needs. These determinations are used to establish short- and long-term treatment goals in the patient's treatment plan.
confidentiality regulations
Rules established by Federal and State agencies to limit disclosure of information about a patient's substance use disorder and treatment (described in 42 CFR, Part 2 § 16). Programs must notify patients of their rights to confidentiality, provide a written summary of these rights, and establish written procedures regulating access to and use of patient records.
consent to treatment. Form completed with and signed by an applicant for MAT and by designated treatment program staff members, which verifies that the applicant has been informed of and understands program procedures and his or her rights and treatment goals, risks, and performance expectations.
contingency contracting
Use of preestablished, mutually agreed-on privileges (e.g., take-home dosing) or consequences (e.g., loss of privileges) to motivate improvements in treatment outcomes. Many experts agree that negative contingencies in MAT (e.g., reduction in medication) are neither effective nor ethical and should be avoided.
continuing-care phase
Optional phase of MAT in which patients who have completed medically supervised withdrawal from treatment medication and are leading socially productive lives continue to maintain regular contact with their treatment program.
co-occurring disorder. In this TIP, a mental disorder, according to DSM-IV diagnosis, that is present in an individual who is admitted to an OTP.
counseling
In MAT, a treatment service in which a trained counselor and a case manager evaluate both a patient's external circumstances and immediate treatment progress and offer appropriate advice and assistance or referral to other experts and services as needed. A major objective in MAT is to provide skills and support for a substance-free lifestyle and encourage abstinence from alcohol and other psychoactive substances. Compare psychotherapy.
craving
Urgent, seemingly overpowering desire to use a substance, which often is associated with tension, anxiety, or other dysphoric, depressive, or negative affective states.
cross-tolerance. Condition in which repeated administration of a drug results in diminished effects not only for that drug but also for one or more drugs from a similar class to which the individual has not been exposed recently.
cultural competence
Capacity of a service provider or organization to understand and work effectively in accord with the beliefs and practices of persons from a given ethnic/racial/religious/social group or sexual orientation. It includes the holding of knowledge, skills, and attitudes that allow the treatment provider and program to understand the full context of a patient's current and past socioenvironmental situation.
cultural diversity
Differences in backgrounds and beliefs that may affect the way groups of patients in OTPs and individuals within these groups view the world and their place in it, their substance use, and treatment.
-D-
dependence
State of physical adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, and/or decreasing blood level of a substance and/or administration of an antagonist. Compare addiction.
detoxification
In this TIP, treatment for addiction to an illicit substance in which the substance is eliminated gradually from a patient's body while various types and levels of reinforcing treatment are provided to alleviate adverse physical or psychological reactions to the withdrawal process. This TIP avoids the term “detoxification” to designate the process of dose tapering from maintenance medication because that term incorrectly suggests that opioid treatment medications are toxic. Compare medically supervised withdrawal.
diagnosis. Classification of the nature and severity of the substance use, medical, mental health, or other problems present in a patient who is addicted to opioids. DSM-IV-TR and ICD-10 classifications commonly are used to classify substance use and mental disorders.
discharge. Release from or discontinuation of enrollment in treatment when maximum benefit has been achieved or when a patient is deemed no longer suitable for treatment. See administrative discharge, involuntary discharge.
diversion
Sale or other unauthorized distribution of a controlled substance, usually for a purpose other than the prescribed and legitimate treatment of a medical or mental disorder.
diversion control plan. Documented procedures to reduce the possibility that controlled substances are used for other than their legitimate use. Federal opioid treatment standards (42 CFR, Part 8 § 12(c)(2)) require a diversion control plan in an OTP as part of its quality assurance program
dosage determination
Process of identifying the amount of medication that will minimize withdrawal symptoms and craving in patients in MAT and eliminate their opioid abuse. Much evidence supports a linear relationship among the amount of medication provided, the timeframe over which it is allowed to act before another dose is administered (dose frequency), and treatment response.
dose tapering. See medically supervised withdrawal.
drug interaction
Action of one drug on the effectiveness or toxicity of another drug.
drug testing. Examination of an individual to determine the presence or absence of illicit or nonprescribed drugs or alcohol or to confirm maintenance levels of treatment medications, usually by a methodology that has been approved by the OTP medical director based on informed medical judgment. OTPs also must conform to State laws and regulations in this area. See blood testing, oral-fluid drug testing, urine testing.
duration of action. Length of time that a treatment medication effectively prevents withdrawal symptoms or craving. Duration of action can be affected by many factors, including drug interactions, certain diseases and medical conditions, patient cross-tolerance, and the relative affinity of a medication for its targeted cell receptor.
-E-
eligibility.
See treatment eligibility.
elimination half-life.
Time required after administration of a substance (e.g., methadone) for one-half the dose to leave the body. Elimination half-life affects the duration of action of a substance or medication and can be influenced by patient factors such as absorption rate, variable metabolism and protein binding, changes in urinary pH, concomitant medications, diet, physical condition, age, pregnancy, and even use of vitamins and herbal products.
-H-
half-life.
See elimination half-life.
hepatitis C
Viral disease of the liver that is the leading cause of cirrhosis in the United States and a particular concern in MAT because of the high incidence of the disease and spread of the infection among people who inject drugs.
high-risk behavior
Activity that increases the likelihood that a recovering patient in substance abuse treatment will relapse to substance use or contract a substance use-related disorder, such as an infectious disease.
hospital-based treatment
Treatment of opioid addiction and related complications that requires patient residency for some period in a hospital setting or outpatient treatment in a hospital-linked facility to ensure that necessary services and levels of care are available.
-I-
iatrogenic opioid addiction
Addiction resulting from medical use of an opioid (i.e., under physician supervision), usually for pain management.
induction
Initial treatment process of adjusting maintenance medication dosage levels until a patient attains stabilization.
induction stage
The period of opioid pharmacotherapy, usually during the acute phase of treatment, in which steady-state blood levels of a medication are achieved.
intake
Initial screening of applicants for admission to an OTP.
intensity of treatment
Frequency and method of delivery for therapeutic services. In this TIP and in American Society of Addiction Medicine Patient Placement Criteria, intensity of treatment is one component, along with treatment setting, that determines the level of care for a patient. Levels of care are adjusted during MAT based on patient needs and the treatment plan. See, for example, intensive inpatient treatment and intensive outpatient treatment.
intensive inpatient treatment
Level of care in which addiction professionals and clinicians provide a regimen of around-the-clock evaluation, care, and therapy in an inpatient setting. Involvement of physicians can range from monitoring multidisciplinary staff members to direct management of cases, depending on the severity of patients' problems.
intensive outpatient treatment
Level of care (possibly including partial hospitalization) in which addiction professionals and clinicians provide therapeutic services to clients who live at home or in special residences. Treatment is delivered in two to five regularly scheduled sessions per week totaling 6 to 24 hours per week. Many treatment services and levels of care are compatible with intensive outpatient treatment, but most programs include structured psychoeducation and group counseling.
interim maintenance treatment
Time-limited pharmacotherapeutic regimen in conjunction with appropriate medical services while a patient awaits transfer to an OTP that provides comprehensive maintenance treatment (42 CFR, Part 8 § 2).
intervention
The process of providing care to a patient or taking action to modify a symptom, an effect, or a behavior. Also the process of interacting after assessment with a patient who is substance addicted to present a diagnosis and recommend and negotiate a treatment plan. Also frequently used as a synonym for treatment. Types of intervention can include crisis intervention, brief intervention, and long-term intervention.
involuntary discharge
Formal discontinuation of a patient's enrollment in an OTP without patient consent, usually for reasons related to program operations, safety, or treatment compliance—for example, violence or threats of violence; buying and selling drugs; repeated loitering; flagrant noncompliance with program rules resulting in an observable, negative impact on the program, staff, and other patients; nonpayment of fees; and incarceration or other confinement. See administrative discharge.
-J-
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
One of several SAMHSA-approved accreditation organizations charged with ensuring that OTPs meet the standards set forth in Federal regulations and SAMHSA guidelines.
-L-
LAAM.
See levo-alpha acetyl methadol.
level of care
The setting or combination of settings in which the appropriate intensities and types of treatment services can be provided for individual patients.
levo-alpha acetyl methadol (LAAM; trade name ORLAAM)
An opioid agonist medication derived from methadone that is effective for up to 72 hours. Reports in 2000 and 2001 of potential arrhythmogenic cardiac effects of LAAM led to tightening of guidelines, including recommendations that LAAM no longer be used for first-line therapy but only for treatment of patients who already have used it successfully or do not show an acceptable response to other addiction treatments. At this writing, LAAM's future availability for opioid pharmacotherapy is doubtful.
-M-
maintenance dosage
Amount of medication that is adequate to achieve desired therapeutic effects for 24 hours or more, with allowance for day-to-day fluctuations.
medication
Medication used for ongoing treatment of opioid addiction.
maintenance treatment
Dispensing of an opioid addiction medication at stable dosage levels for a period in excess of 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 § 2).
medical maintenance. (1) Phase of MAT and type of treatment by an OTP, medication unit, or physician affiliated with an OTP in which a person who has achieved a stable lifestyle and has remained abstinent from illicit drugs for at least 2 years (longer in some States) receives ongoing pharmacotherapy with methadone, buprenorphine, or LAAM but no longer requires the structure or frequency of psychosocial treatment services provided in an OTP, as determined by the OTP medical director. (2) Medical maintenance also can be provided by physicians using buprenorphine or naltrexone (42 CFR, Part 8 § 12(i)(3)(vi); 42 CFR, Part 8 § 11(h)).
medically supervised withdrawal. Dispensing of a maintenance medication in gradually decreasing doses to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of opioid drugs. The purpose of medically supervised withdrawal is to bring a patient maintained on maintenance medication to a medication-free state within a target period.
medication-assisted treatment for opioid addiction (MAT)
Type of addiction treatment, usually provided in a certified, licensed OTP or a physician's office-based treatment setting, that provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication, which may be combined with other comprehensive treatment services, including medical and psychosocial services.
medication unit. Facility established as part of, but geographically separate from, an opioid treatment program, from which certified private practitioners or community pharmacists may dispense or administer opioid agonist medications for observed ingestion (42 CFR, Part 8 § 11(i)(1)).
methadone
The most frequently used opioid agonist medication. Methadone is a synthetic opioid that binds to mu opiate receptors and produces a range of mu agonist effects similar to those of short-acting opioids such as morphine and heroin.
methadone maintenance treatment
Dispensing of methadone at stable dosage levels for more than 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 § 2).
mobile treatment services. Substance use treatment provided directly to patients from traveling units or vans, ranging from comprehensive maintenance services (with medication and counseling in one or several mobile units) to more limited care, usually medication maintenance therapy, in conjunction with a fixed-site program offering counseling and other psychosocial services.
multiple substance abuse
Concurrent opioid and other substance use—a serious problem in OTPs. Other substances commonly used by people addicted to opioids include alcohol, amphetamines, benzodiazepines (particularly alprazolam and diazepam), other prescription sedatives, cocaine, marijuana, and nicotine. Patterns of use range from periodic low doses to regular high doses that also can meet criteria for addiction. Some drugs—in particular, high-dose barbiturates—used in combination with opioids are immediately life threatening.
mutual-help program. Program offering the benefits of peer support to people who are substance addicted, through attendance at group meetings and other activities. Twelve-Step programs are one type of mutual-help program.
-N-
naloxone
Short-acting opioid antagonist. Because of its higher affinity than that of opioids for mu opiate receptors, naloxone displaces opioids from these receptors and can precipitate withdrawal, but it does not activate the mu receptors, nor does it cause the euphoria and other effects associated with opioid drugs. Naloxone is not FDA approved for long-term therapy for opioid addiction, except in the combination buprenorphine-naloxone tablet. Some programs use naloxone to evaluate an individual's level of opioid dependence. See naloxone challenge test.
naloxone challenge test. Test in which naloxone is administered to verify an applicant's current opioid dependence and eligibility for admission to an OTP. Withdrawal symptoms evoked by naloxone's antagonist interaction with opioids confirm an individual's current dependence.
naltrexone. Derivative of naloxone and the only opioid antagonist approved for use alone in long-term treatment of people with opioid addiction. Naltrexone is used primarily after medically supervised withdrawal from opioids to prevent drug relapse in selected, well-motivated patients.
narcotic
See opioid (preferred usage).
not-in-my-backyard (NIMBY) syndrome
Informal name used to label opposition to the placement of OTPs in communities.
-O-
office-based opioid treatment (OBOT)
MAT provided in a physician's office or health care setting other than an OTP (42 CFR, Part 8 § 11(i)(1)). See medication unit.
opiate receptors
Areas on cell surfaces in the central nervous system that are activated by opioid molecules to produce the effects associated with opioid use, such as euphoria and analgesia. Opiate receptors are activated or blocked by opioid agonist or antagonist medications, respectively, to mediate the effects of opioids on the body. Mu and kappa opiate receptor groups principally are involved in this activity.
opioid
Natural derivative of opium or synthetic psychoactive substance that has effects similar to morphine or is capable of conversion into a drug having such effects. One effect of opioid drugs is their addiction-forming or addiction-sustaining liability.
opioid addiction
Cluster of cognitive, behavioral, and physiological symptoms resulting from continuation of opioid use despite significant related problems. Opioid addiction is characterized by repeated self-administration that usually results in opioid tolerance, withdrawal symptoms, and compulsive drug taking.
opioid addiction treatment
Dispensing of approved medication to prevent withdrawal and craving during the elimination of opioid use by a patient in MAT, with or without a comprehensive range of medical and rehabilitation services or medication prescribed when necessary to alleviate the adverse medical, psychological, or physical effects. This term encompasses medically supervised withdrawal, maintenance treatment, comprehensive maintenance treatment, and, under restricted timeframes, interim maintenance treatment (adapted from 42 CFR, Part 8 § 2).
opioid agonist. Drug that has an affinity for and stimulates physiologic activity at cell receptors in the central nervous system normally stimulated by opioids. Methadone and LAAM are opioid agonists.
opioid antagonist
Drug that binds to cell receptors in the central nervous system that normally are bound by opioid psychoactive substances and that blocks the activity of opioids at these receptors without producing the physiologic activity produced by opioid agonists. Naltrexone is an opioid antagonist.
opioid partial agonist
Drug that binds to, but incompletely activates, opiate receptors in the central nervous system, producing effects similar to those of a full opioid agonist but, at increasing doses, does not produce as great an agonist effect as do increased doses of a full agonist. Buprenorphine is a partial opioid agonist.
opioid treatment program (OTP)
SAMHSA-certified program, usually comprising a facility, staff, administration, patients, and services, that engages in supervised assessment and treatment, using methadone, buprenorphine, LAAM, or naltrexone, of individuals who are addicted to opioids. An OTP can exist in a number of settings, including, but not limited to, intensive outpatient, residential, and hospital settings. Services may include medically supervised withdrawal and/or maintenance treatment, along with various levels of medical, psychiatric, psychosocial, and other types of supportive care.
oral-fluid drug testing
Method of identifying evidence of opioid and other psychoactive substance use and measuring the levels of substances or medications in the body by examining patient saliva for the presence and concentrations of identifiable drugs and their metabolites. Oral-fluid testing must be approved for drug testing by the OTP medical director for patient and program needs.
orientation. See patient orientation.
outcome-based evaluation
Measurement of program effectiveness based on patient response to treatment, such as measures of reduction in opioid and nonopioid drug use and improvement in social function. An outcome-based evaluation system requires that the measures and instruments that are used reflect a consensus of the field, provide incentives to programs to submit data, and include ways to validate and aggregate clinic-level data for national and regional evaluation purposes. Compare process-based evaluation.
outpatient psychosocial program
In this TIP, an approach to MAT that may involve the use of opioid addiction treatment medication for medically supervised withdrawal but not for ongoing maintenance pharmacotherapy. Counseling and other psychosocial interventions are the primary features of outpatient psychosocial treatment programs.
OxyContin ®
Long-acting class II opioid drug usually obtained by prescription for treatment of pain. OxyContin is one of several prescription opioids increasingly obtained by illicit means and abused by people addicted to opioids.
-P-
pain management
Treatment of acute or chronic pain by various treatment methods, often including administration of opioid medications.
patient
Any individual undergoing MAT in an opioid treatment program (42 CFR, Part 8 § 2).
patient advocacy. Term applied to two levels of activity in addiction treatment: (1) a social or political movement working for changes in legislation, policy, and funding to reflect patient concerns and protect their rights (i.e., advocacy for patients) and (2) a philosophy of substance abuse treatment practice maintaining that patients should be involved actively in their own treatment and have rights in its planning and implementation (i.e., advocacy by patients). Much of advocacy is about shifting the system from the directive model to one in which the patient is an empowered, involved participant in treatment decisions. This fits with the growing emphasis on individualized treatment.
patient exception
Special permission requested from and decided by SAMHSA for a substance abuse treatment program to dispense or arrange for the offsite delivery of maintenance medication to a patient in an emergency or hardship situation when the patient does not meet regulatory requirements for such services. Patient exceptions are requested on SAMHSA form SMA-168. In most States, patient exceptions are contingent on the approval of the appropriate State Methadone Authority.
patient handbook
Document provided to a patient in an OTP that contains the information he or she should know to understand MAT, program offerings, program structure, and patient limits and privileges, as well as rights and responsibilities of patients and treatment providers.
patient matching. See patient-treatment matching.
patient motivation for change
Relative readiness to modify one's lifestyle and the sincerity and purposefulness of a patient in an OTP toward achieving the goals of MAT.
patient orientation
Planned introduction to the structure, services, offerings, and methods used in an OTP and to patients' and treatment providers' rights and responsibilities within the program.
patient referral. Alternative to providing all necessary treatment services and levels of care at the program site by collaboratively outsourcing some services to other settings and providers. When a patient must obtain comprehensive services in multiple settings, treatment program staff members should arrange the referrals, monitor patient progress, and coordinate care.
patient-treatment matching
Process of individualizing therapeutic resources to patient needs and preferences, ideally by a participatory process involving both the treatment provider and patient. Because many people addicted to opioids have multiple needs, effective patient-treatment matching in an OTP is a three-step process: (1) assessing, (2) selecting the most suitable treatment modality and site, and (3) identifying the most appropriate services.
pharmacology
Science that addresses the origin, nature, chemistry, effects, and uses of medications and drugs.
pharmacotherapy
Treatment of disease with prescribed medications.
preliminary assessment
Basic assessment occurring before admission to a treatment program, in which an individual's eligibility for entry and level of any psychosocial crisis are determined.
prevalence
Number of cases of a disease in a population, either at a point in time (point prevalence) or over a period (period prevalence). Prevalence rate is the fraction of people in a population who have a disease or condition at one time (the numerator of the rate is the number of existing cases of the condition at a specified time and the denominator is the total population).
process-based evaluation
Evaluation of program effectiveness based on compliance with procedural standards. Compare outcome-based evaluation.
psychiatric comorbidity
See co-occurring disorder.
psychoactive drug
A substance that affects the mind, thoughts, feelings, and sometimes behaviors.
psychotherapy. Treatment service provided to patients in a comprehensive opioid treatment program, either directly or by referral, in which a trained therapist evaluates and treats patients for diagnosed psychiatric problems. Compare counseling.
-R-
readmission
Reenrollment of a patient who previously left an opioid treatment program. Readmission usually is preceded by a review of the patient's records to determine whether and how the individual's treatment plan should be modified.
referral
See patient referral.
rehabilitative phase
Phase of MAT in which patients who are stabilized on opioid treatment medication continue to eliminate addictive substances from their lives while gaining control of other major life domains (e.g., medical problems, co-occurring disorders, vocational and educational needs, family circumstances, legal issues).
relapse
Breakdown or setback in a person's attempt to change or modify a particular behavior; an unfolding process in which the resumption of compulsive substance use is the last event in a series of maladaptive responses to internal or external stressors or stimuli.
remission. State in which a mental or physical disorder has been overcome or a disease process halted.
residential treatment
Therapy received within the context of a cooperative living arrangement. Residential treatment programs vary in duration and intensity of services and general philosophy.
retention in treatment
Period during which a patient is able and willing to remain in therapy, which is influenced by a combination of patient and program characteristics. Retention in treatment should be considered the product of a continuing therapeutic relationship between recovering patients and their treatment providers.
-S-
saliva testing
See oral-fluid drug testing.
screening
Process of determining whether a prospective patient has a substance use disorder before admission to treatment. Screening usually involves use of one or more standardized techniques, most of which include a questionnaire or a structured interview. Screening also may include observation of known presenting complaints and symptoms that are indicators of substance use disorders.
sedative
Medication with central nervous system sedating and tranquilizing properties. An example is any of the benzodiazepines. Most sedatives also promote sleep. Overdoses of sedatives can lead to dangerous respiratory depression (slowed breathing).
self-help program
See mutual-help program.
self-medication
Medically unsanctioned use of drugs by a person to relieve any of a variety of problems (e.g., pain, depression).
serum half-life
Time required for the amount of a compound (e.g., an opioid) in blood serum to be halved through metabolism or excretion.
side effect
Consequence (especially an adverse result) other than that for which a drug is used—especially the result produced on a tissue or organ system other than that being targeted.
stabilization (stability)
Process of providing immediate assistance (as with an opioid agonist) to eliminate withdrawal symptoms and drug craving.
stand-alone clinic
Facility that generally offers a comprehensive range of medication and psychosocial services for patients who are opioid addicted, including all levels of care and phases of treatment. Compare hospital-based treatment.
State Authority
Agency (sometimes referred to as a “Single State Agency”) designated by the governor or another official assigned by the governor to exercise the responsibility and authority within a State or territory for governing the treatment of addiction to opioid drugs (adapted from 42 CFR, Part 8 § 2).
stigma
Negative association attached to an activity or condition; a cause of shame or embarrassment. Stigma commonly is associated with opioid addiction and MAT.
stimulant
Agent, drug, or medication that produces stimulation. In this TIP, stimulant usually refers to drugs that stimulate the central nervous system (e.g., amphetamines, cocaine).
substance addiction
See opioid addiction
substance dependence
Dependence. substance use disorder (frequently referred to as substance abuse or dependence
Maladaptive pattern of drug or alcohol use manifested by recurrent, significant adverse consequences related to the repeated use of these drugs or alcohol. The substance-related problem must have persisted and occurred repeatedly during a 12-month period. It can occur sporadically and mainly be associated with social or interpersonal problems, or it can occur regularly and be associated with medical and mental problems, often including tolerance and withdrawal.
supportive-care phase
Phase of MAT in which patients maintain abstinence from substances and continue on maintenance medication while receiving other types of intervention as needed to resume primary responsibility for other aspects of their lives.
-T-
take-home medication
Opioid addiction treatment medication dispensed to patients for unsupervised self-administration.
tapering phase
Phase of MAT in which patients receiving medication maintenance attempt gradually to eliminate their treatment medication (e.g., methadone) while remaining abstinent from illicit substances.
therapeutic alliance.
Joining of patients and their treatment providers in an effective collaboration to assess and treat patients' substance use disorders.
therapeutic community (TC)
Consciously designed social environment or residential treatment setting in which social and group processes are harnessed with treatment intent. A TC promotes abstinence from substance use and seeks to decrease antisocial behavior and effect a global change in lifestyle, including attitudes and values. A TC views substance abuse as a disorder of the whole person, reflecting problems in conduct, attitudes, moods, values, and emotional management. Treatment focuses on drug abstinence, coupled with social and psychological change requiring a multidimensional effort along with intensive mutual help and support.
therapeutic dosage
Combination of amount of medication and frequency and timing of administration that is determined by laboratory analysis, professional observation, or patient self-report to be beneficial to control and ameliorate symptoms of withdrawal from addiction and drug-seeking behavior. Therapeutic dosage levels should be determined by what each patient needs to remain stable.
tolerance
Condition of needing increased amounts of an opioid to achieve intoxication or a desired effect; condition in which continued use of the same amount of a substance has a markedly diminished effect.
treatment barrier
Anything that hinders treatment. Examples include financial problems, language difficulties, ethnic and social attitudes, logistics (caring for children, transportation), and unhelpful patient behaviors (tardiness, missed appointments).
treatment efficacy
Ability of an intervention or medication in expert hands and under ideal circumstances to produce the desired therapeutic effect.
treatment eligibility
Relative qualification of a prospective patient for admission to an OTP according to Federal, State, or third-party payer requirements. In general, Federal guidelines are minimum requirements and restrict admission to individuals who have been demonstrably dependent on opioids for 1 year; however, certain high-risk populations including pregnant women are admitted more quickly.
treatment intensity
Frequency and methods for delivery of therapeutic services. OTPs aim to establish levels of treatment intensity that match patients' needs.
treatment outcomes.
Results of therapy, including decreased use of illicit psychoactive substances, improved physical and emotional health, decreased antisocial activities, and improved social functioning; considered the best indicator of treatment program effectiveness.
treatment plan
Documented therapeutic approach for each patient that outlines attainable short-term goals mutually acceptable to the patient and the OTP and that specifies the services to be provided and their frequency and schedule (adapted from 42 CFR, Part 8 § 2).
treatment retention.See retention in treatment.
12-Step program.
Self-help program requiring mastery of a set of steps to achieve and maintain abstinence, based on the program of Alcoholics Anonymous. Many addiction treatment programs use a 12-Step structure or philosophy as a construct for treatment design.
-U-
urine drug testing
Most common laboratory assessment technique in addiction treatment, which involves analysis of urine samples from patients for the presence or absence of specific drugs. Originally used as a measure of program effectiveness, urine testing now is used to make programmatic decisions, monitor psychoactive substance use, adjust medication dosage, and decide whether a patient is responsible enough to receive take-home medication. Methods of urine testing vary widely.
-V-
voluntary discharge
Discharge from an OTP that is initiated by the patient. Tapering from medication is negotiated among the patient, program physician, and treatment providers.
-W-
withdrawal
Reduction and elimination of substance use. See medically supervised withdrawal, withdrawal syndrome.
withdrawal syndrome (or withdrawal)
Predictable constellation of signs and symptoms after abrupt discontinuation of or rapid decrease in use of a substance that has been used consistently for a period. Signs and symptoms of withdrawal are usually opposite to the direct pharmacological effects of a psychoactive substance
With appropriate credit to:
National Library of Medicine
-A-
abstinence
Nonuse of alcohol or any illicit drugs, as well as nonabuse of medications normally obtained by prescription or over the counter.
acute phase
Initial and usually the most symptomatic intensive-treatment phase
addiction
Combination of the physical dependence on, behavioral manifestations of the use of, and subjective sense of need and craving for a psychoactive substance, leading to compulsive use of the substance either for its positive effects or to avoid negative effects associated with abstinence from that substance. Compare dependence.
administrative discharge
Release or discharge of a patient from an OTP, often against the patient's wishes. See involuntary discharge. admission. Formal process of enrolling patients in an OTP, carried out by qualified personnel who determine that the patient meets acceptable medical criteria for treatment. Admission can include orientation to the program and an introduction to peer support, patient rights, services, rules, and treatment requirements related to MAT.
agonist. See opioid agonist.
analgesic
A compound that alleviates pain without causing loss of consciousness. Opioid analgesics are a class of compounds that bind to specific receptors in the central nervous system to block the perception of pain or affect the emotional response to pain. Such compounds include opium and its derivatives, as well as a number of synthetic compounds. Chronic administration or abuse of opioid analgesics may lead to addiction.
antagonist. See opioid antagonist.
assessment
Process of identifying the precise nature and extent of a patient's substance use disorder and other medical, mental health, and social problems as a basis for treatment planning. Assessment usually begins during program admission and continues throughout treatment. It includes a personal substance abuse history, physical examination, laboratory evaluation, and determination of disease morbidity. Severity of disease often is assessed further in terms of physiologic dependence, organ system damage, and psychosocial morbidity. Assessment also may involve determining patient motivation and readiness for change.
assessment tools
Instruments (e.g., questionnaires) used to capture the range of patient variables affecting treatment planning, methods, and outcomes. Valid assessment tools contain quantifiable indicators to measure patient progress and to track patients through treatment.
Axis I. DSM-IV-TR disorder classification comprising definitions and descriptions of major disorders (i.e., psychotic, mood, and substance use disorders) that may require clinical attention.
-B-
benzodiazepines
Group of medications having a common molecular structure and similar pharmacological activity, including antianxiety, sedative, hypnotic, amnestic, anticonvulsant, and muscle-relaxing effects. Benzodiazepines are among the most widely prescribed medications (e.g., diazepam, chlordiazepoxide, clonazepam, alprazolam, lorazepam).
best-treatment practices. Methods determined, often by a consensus of experts, to be optimal for defined therapeutic situations. Such guidelines usually are based on both an analysis of published research findings and the experience of experts.
blood testing
Identifying evidence of opioid and other psychoactive substance use and measuring the levels of substances or medications in the body by examining patient blood specimens for the presence and concentrations of identifiable drugs and their metabolites.
buprenorphine
Partial opioid agonist approved by FDA for use in detoxification or maintenance treatment of opioid addiction and marketed under the trade names Subutex® and Suboxone® (the latter also containing naloxone).
-C-
civil commitment
Legal process that permits individuals to be confined against their will in psychiatric or other treatment facilities, which usually is justified by determining that a patient is a threat to himself or herself or others. Although statutes permitting involuntary civil commitment may remain in some States, such laws rarely have been used to commit people who abuse substances and are not under criminal justice jurisdiction.
Commission on Accreditation of Rehabilitation Facilities (CARF)
One of several SAMHSA-approved accreditation organizations charged with ensuring that OTPs meet the standards set forth in Federal regulations and SAMHSA guidelines. Also known as CARF… The Rehabilitation Accreditation Commission.
comprehensive maintenance treatment
Continuous therapy with medication in conjunction with a wide range of medical, psychiatric, and psychosocial services. Compare medical maintenance.
comprehensive treatment assessment
Evaluation made after formal admission to an OTP, in which trained staff members determine the range and severity of a patient's problems and the patient's service needs. These determinations are used to establish short- and long-term treatment goals in the patient's treatment plan.
confidentiality regulations
Rules established by Federal and State agencies to limit disclosure of information about a patient's substance use disorder and treatment (described in 42 CFR, Part 2 § 16). Programs must notify patients of their rights to confidentiality, provide a written summary of these rights, and establish written procedures regulating access to and use of patient records.
consent to treatment. Form completed with and signed by an applicant for MAT and by designated treatment program staff members, which verifies that the applicant has been informed of and understands program procedures and his or her rights and treatment goals, risks, and performance expectations.
contingency contracting
Use of preestablished, mutually agreed-on privileges (e.g., take-home dosing) or consequences (e.g., loss of privileges) to motivate improvements in treatment outcomes. Many experts agree that negative contingencies in MAT (e.g., reduction in medication) are neither effective nor ethical and should be avoided.
continuing-care phase
Optional phase of MAT in which patients who have completed medically supervised withdrawal from treatment medication and are leading socially productive lives continue to maintain regular contact with their treatment program.
co-occurring disorder. In this TIP, a mental disorder, according to DSM-IV diagnosis, that is present in an individual who is admitted to an OTP.
counseling
In MAT, a treatment service in which a trained counselor and a case manager evaluate both a patient's external circumstances and immediate treatment progress and offer appropriate advice and assistance or referral to other experts and services as needed. A major objective in MAT is to provide skills and support for a substance-free lifestyle and encourage abstinence from alcohol and other psychoactive substances. Compare psychotherapy.
craving
Urgent, seemingly overpowering desire to use a substance, which often is associated with tension, anxiety, or other dysphoric, depressive, or negative affective states.
cross-tolerance. Condition in which repeated administration of a drug results in diminished effects not only for that drug but also for one or more drugs from a similar class to which the individual has not been exposed recently.
cultural competence
Capacity of a service provider or organization to understand and work effectively in accord with the beliefs and practices of persons from a given ethnic/racial/religious/social group or sexual orientation. It includes the holding of knowledge, skills, and attitudes that allow the treatment provider and program to understand the full context of a patient's current and past socioenvironmental situation.
cultural diversity
Differences in backgrounds and beliefs that may affect the way groups of patients in OTPs and individuals within these groups view the world and their place in it, their substance use, and treatment.
-D-
dependence
State of physical adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, and/or decreasing blood level of a substance and/or administration of an antagonist. Compare addiction.
detoxification
In this TIP, treatment for addiction to an illicit substance in which the substance is eliminated gradually from a patient's body while various types and levels of reinforcing treatment are provided to alleviate adverse physical or psychological reactions to the withdrawal process. This TIP avoids the term “detoxification” to designate the process of dose tapering from maintenance medication because that term incorrectly suggests that opioid treatment medications are toxic. Compare medically supervised withdrawal.
diagnosis. Classification of the nature and severity of the substance use, medical, mental health, or other problems present in a patient who is addicted to opioids. DSM-IV-TR and ICD-10 classifications commonly are used to classify substance use and mental disorders.
discharge. Release from or discontinuation of enrollment in treatment when maximum benefit has been achieved or when a patient is deemed no longer suitable for treatment. See administrative discharge, involuntary discharge.
diversion
Sale or other unauthorized distribution of a controlled substance, usually for a purpose other than the prescribed and legitimate treatment of a medical or mental disorder.
diversion control plan. Documented procedures to reduce the possibility that controlled substances are used for other than their legitimate use. Federal opioid treatment standards (42 CFR, Part 8 § 12(c)(2)) require a diversion control plan in an OTP as part of its quality assurance program
dosage determination
Process of identifying the amount of medication that will minimize withdrawal symptoms and craving in patients in MAT and eliminate their opioid abuse. Much evidence supports a linear relationship among the amount of medication provided, the timeframe over which it is allowed to act before another dose is administered (dose frequency), and treatment response.
dose tapering. See medically supervised withdrawal.
drug interaction
Action of one drug on the effectiveness or toxicity of another drug.
drug testing. Examination of an individual to determine the presence or absence of illicit or nonprescribed drugs or alcohol or to confirm maintenance levels of treatment medications, usually by a methodology that has been approved by the OTP medical director based on informed medical judgment. OTPs also must conform to State laws and regulations in this area. See blood testing, oral-fluid drug testing, urine testing.
duration of action. Length of time that a treatment medication effectively prevents withdrawal symptoms or craving. Duration of action can be affected by many factors, including drug interactions, certain diseases and medical conditions, patient cross-tolerance, and the relative affinity of a medication for its targeted cell receptor.
-E-
eligibility.
See treatment eligibility.
elimination half-life.
Time required after administration of a substance (e.g., methadone) for one-half the dose to leave the body. Elimination half-life affects the duration of action of a substance or medication and can be influenced by patient factors such as absorption rate, variable metabolism and protein binding, changes in urinary pH, concomitant medications, diet, physical condition, age, pregnancy, and even use of vitamins and herbal products.
-H-
half-life.
See elimination half-life.
hepatitis C
Viral disease of the liver that is the leading cause of cirrhosis in the United States and a particular concern in MAT because of the high incidence of the disease and spread of the infection among people who inject drugs.
high-risk behavior
Activity that increases the likelihood that a recovering patient in substance abuse treatment will relapse to substance use or contract a substance use-related disorder, such as an infectious disease.
hospital-based treatment
Treatment of opioid addiction and related complications that requires patient residency for some period in a hospital setting or outpatient treatment in a hospital-linked facility to ensure that necessary services and levels of care are available.
-I-
iatrogenic opioid addiction
Addiction resulting from medical use of an opioid (i.e., under physician supervision), usually for pain management.
induction
Initial treatment process of adjusting maintenance medication dosage levels until a patient attains stabilization.
induction stage
The period of opioid pharmacotherapy, usually during the acute phase of treatment, in which steady-state blood levels of a medication are achieved.
intake
Initial screening of applicants for admission to an OTP.
intensity of treatment
Frequency and method of delivery for therapeutic services. In this TIP and in American Society of Addiction Medicine Patient Placement Criteria, intensity of treatment is one component, along with treatment setting, that determines the level of care for a patient. Levels of care are adjusted during MAT based on patient needs and the treatment plan. See, for example, intensive inpatient treatment and intensive outpatient treatment.
intensive inpatient treatment
Level of care in which addiction professionals and clinicians provide a regimen of around-the-clock evaluation, care, and therapy in an inpatient setting. Involvement of physicians can range from monitoring multidisciplinary staff members to direct management of cases, depending on the severity of patients' problems.
intensive outpatient treatment
Level of care (possibly including partial hospitalization) in which addiction professionals and clinicians provide therapeutic services to clients who live at home or in special residences. Treatment is delivered in two to five regularly scheduled sessions per week totaling 6 to 24 hours per week. Many treatment services and levels of care are compatible with intensive outpatient treatment, but most programs include structured psychoeducation and group counseling.
interim maintenance treatment
Time-limited pharmacotherapeutic regimen in conjunction with appropriate medical services while a patient awaits transfer to an OTP that provides comprehensive maintenance treatment (42 CFR, Part 8 § 2).
intervention
The process of providing care to a patient or taking action to modify a symptom, an effect, or a behavior. Also the process of interacting after assessment with a patient who is substance addicted to present a diagnosis and recommend and negotiate a treatment plan. Also frequently used as a synonym for treatment. Types of intervention can include crisis intervention, brief intervention, and long-term intervention.
involuntary discharge
Formal discontinuation of a patient's enrollment in an OTP without patient consent, usually for reasons related to program operations, safety, or treatment compliance—for example, violence or threats of violence; buying and selling drugs; repeated loitering; flagrant noncompliance with program rules resulting in an observable, negative impact on the program, staff, and other patients; nonpayment of fees; and incarceration or other confinement. See administrative discharge.
-J-
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
One of several SAMHSA-approved accreditation organizations charged with ensuring that OTPs meet the standards set forth in Federal regulations and SAMHSA guidelines.
-L-
LAAM.
See levo-alpha acetyl methadol.
level of care
The setting or combination of settings in which the appropriate intensities and types of treatment services can be provided for individual patients.
levo-alpha acetyl methadol (LAAM; trade name ORLAAM)
An opioid agonist medication derived from methadone that is effective for up to 72 hours. Reports in 2000 and 2001 of potential arrhythmogenic cardiac effects of LAAM led to tightening of guidelines, including recommendations that LAAM no longer be used for first-line therapy but only for treatment of patients who already have used it successfully or do not show an acceptable response to other addiction treatments. At this writing, LAAM's future availability for opioid pharmacotherapy is doubtful.
-M-
maintenance dosage
Amount of medication that is adequate to achieve desired therapeutic effects for 24 hours or more, with allowance for day-to-day fluctuations.
medication
Medication used for ongoing treatment of opioid addiction.
maintenance treatment
Dispensing of an opioid addiction medication at stable dosage levels for a period in excess of 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 § 2).
medical maintenance. (1) Phase of MAT and type of treatment by an OTP, medication unit, or physician affiliated with an OTP in which a person who has achieved a stable lifestyle and has remained abstinent from illicit drugs for at least 2 years (longer in some States) receives ongoing pharmacotherapy with methadone, buprenorphine, or LAAM but no longer requires the structure or frequency of psychosocial treatment services provided in an OTP, as determined by the OTP medical director. (2) Medical maintenance also can be provided by physicians using buprenorphine or naltrexone (42 CFR, Part 8 § 12(i)(3)(vi); 42 CFR, Part 8 § 11(h)).
medically supervised withdrawal. Dispensing of a maintenance medication in gradually decreasing doses to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of opioid drugs. The purpose of medically supervised withdrawal is to bring a patient maintained on maintenance medication to a medication-free state within a target period.
medication-assisted treatment for opioid addiction (MAT)
Type of addiction treatment, usually provided in a certified, licensed OTP or a physician's office-based treatment setting, that provides maintenance pharmacotherapy using an opioid agonist, a partial agonist, or an antagonist medication, which may be combined with other comprehensive treatment services, including medical and psychosocial services.
medication unit. Facility established as part of, but geographically separate from, an opioid treatment program, from which certified private practitioners or community pharmacists may dispense or administer opioid agonist medications for observed ingestion (42 CFR, Part 8 § 11(i)(1)).
methadone
The most frequently used opioid agonist medication. Methadone is a synthetic opioid that binds to mu opiate receptors and produces a range of mu agonist effects similar to those of short-acting opioids such as morphine and heroin.
methadone maintenance treatment
Dispensing of methadone at stable dosage levels for more than 21 days in the supervised treatment of an individual for opioid addiction (42 CFR, Part 8 § 2).
mobile treatment services. Substance use treatment provided directly to patients from traveling units or vans, ranging from comprehensive maintenance services (with medication and counseling in one or several mobile units) to more limited care, usually medication maintenance therapy, in conjunction with a fixed-site program offering counseling and other psychosocial services.
multiple substance abuse
Concurrent opioid and other substance use—a serious problem in OTPs. Other substances commonly used by people addicted to opioids include alcohol, amphetamines, benzodiazepines (particularly alprazolam and diazepam), other prescription sedatives, cocaine, marijuana, and nicotine. Patterns of use range from periodic low doses to regular high doses that also can meet criteria for addiction. Some drugs—in particular, high-dose barbiturates—used in combination with opioids are immediately life threatening.
mutual-help program. Program offering the benefits of peer support to people who are substance addicted, through attendance at group meetings and other activities. Twelve-Step programs are one type of mutual-help program.
-N-
naloxone
Short-acting opioid antagonist. Because of its higher affinity than that of opioids for mu opiate receptors, naloxone displaces opioids from these receptors and can precipitate withdrawal, but it does not activate the mu receptors, nor does it cause the euphoria and other effects associated with opioid drugs. Naloxone is not FDA approved for long-term therapy for opioid addiction, except in the combination buprenorphine-naloxone tablet. Some programs use naloxone to evaluate an individual's level of opioid dependence. See naloxone challenge test.
naloxone challenge test. Test in which naloxone is administered to verify an applicant's current opioid dependence and eligibility for admission to an OTP. Withdrawal symptoms evoked by naloxone's antagonist interaction with opioids confirm an individual's current dependence.
naltrexone. Derivative of naloxone and the only opioid antagonist approved for use alone in long-term treatment of people with opioid addiction. Naltrexone is used primarily after medically supervised withdrawal from opioids to prevent drug relapse in selected, well-motivated patients.
narcotic
See opioid (preferred usage).
not-in-my-backyard (NIMBY) syndrome
Informal name used to label opposition to the placement of OTPs in communities.
-O-
office-based opioid treatment (OBOT)
MAT provided in a physician's office or health care setting other than an OTP (42 CFR, Part 8 § 11(i)(1)). See medication unit.
opiate receptors
Areas on cell surfaces in the central nervous system that are activated by opioid molecules to produce the effects associated with opioid use, such as euphoria and analgesia. Opiate receptors are activated or blocked by opioid agonist or antagonist medications, respectively, to mediate the effects of opioids on the body. Mu and kappa opiate receptor groups principally are involved in this activity.
opioid
Natural derivative of opium or synthetic psychoactive substance that has effects similar to morphine or is capable of conversion into a drug having such effects. One effect of opioid drugs is their addiction-forming or addiction-sustaining liability.
opioid addiction
Cluster of cognitive, behavioral, and physiological symptoms resulting from continuation of opioid use despite significant related problems. Opioid addiction is characterized by repeated self-administration that usually results in opioid tolerance, withdrawal symptoms, and compulsive drug taking.
opioid addiction treatment
Dispensing of approved medication to prevent withdrawal and craving during the elimination of opioid use by a patient in MAT, with or without a comprehensive range of medical and rehabilitation services or medication prescribed when necessary to alleviate the adverse medical, psychological, or physical effects. This term encompasses medically supervised withdrawal, maintenance treatment, comprehensive maintenance treatment, and, under restricted timeframes, interim maintenance treatment (adapted from 42 CFR, Part 8 § 2).
opioid agonist. Drug that has an affinity for and stimulates physiologic activity at cell receptors in the central nervous system normally stimulated by opioids. Methadone and LAAM are opioid agonists.
opioid antagonist
Drug that binds to cell receptors in the central nervous system that normally are bound by opioid psychoactive substances and that blocks the activity of opioids at these receptors without producing the physiologic activity produced by opioid agonists. Naltrexone is an opioid antagonist.
opioid partial agonist
Drug that binds to, but incompletely activates, opiate receptors in the central nervous system, producing effects similar to those of a full opioid agonist but, at increasing doses, does not produce as great an agonist effect as do increased doses of a full agonist. Buprenorphine is a partial opioid agonist.
opioid treatment program (OTP)
SAMHSA-certified program, usually comprising a facility, staff, administration, patients, and services, that engages in supervised assessment and treatment, using methadone, buprenorphine, LAAM, or naltrexone, of individuals who are addicted to opioids. An OTP can exist in a number of settings, including, but not limited to, intensive outpatient, residential, and hospital settings. Services may include medically supervised withdrawal and/or maintenance treatment, along with various levels of medical, psychiatric, psychosocial, and other types of supportive care.
oral-fluid drug testing
Method of identifying evidence of opioid and other psychoactive substance use and measuring the levels of substances or medications in the body by examining patient saliva for the presence and concentrations of identifiable drugs and their metabolites. Oral-fluid testing must be approved for drug testing by the OTP medical director for patient and program needs.
orientation. See patient orientation.
outcome-based evaluation
Measurement of program effectiveness based on patient response to treatment, such as measures of reduction in opioid and nonopioid drug use and improvement in social function. An outcome-based evaluation system requires that the measures and instruments that are used reflect a consensus of the field, provide incentives to programs to submit data, and include ways to validate and aggregate clinic-level data for national and regional evaluation purposes. Compare process-based evaluation.
outpatient psychosocial program
In this TIP, an approach to MAT that may involve the use of opioid addiction treatment medication for medically supervised withdrawal but not for ongoing maintenance pharmacotherapy. Counseling and other psychosocial interventions are the primary features of outpatient psychosocial treatment programs.
OxyContin ®
Long-acting class II opioid drug usually obtained by prescription for treatment of pain. OxyContin is one of several prescription opioids increasingly obtained by illicit means and abused by people addicted to opioids.
-P-
pain management
Treatment of acute or chronic pain by various treatment methods, often including administration of opioid medications.
patient
Any individual undergoing MAT in an opioid treatment program (42 CFR, Part 8 § 2).
patient advocacy. Term applied to two levels of activity in addiction treatment: (1) a social or political movement working for changes in legislation, policy, and funding to reflect patient concerns and protect their rights (i.e., advocacy for patients) and (2) a philosophy of substance abuse treatment practice maintaining that patients should be involved actively in their own treatment and have rights in its planning and implementation (i.e., advocacy by patients). Much of advocacy is about shifting the system from the directive model to one in which the patient is an empowered, involved participant in treatment decisions. This fits with the growing emphasis on individualized treatment.
patient exception
Special permission requested from and decided by SAMHSA for a substance abuse treatment program to dispense or arrange for the offsite delivery of maintenance medication to a patient in an emergency or hardship situation when the patient does not meet regulatory requirements for such services. Patient exceptions are requested on SAMHSA form SMA-168. In most States, patient exceptions are contingent on the approval of the appropriate State Methadone Authority.
patient handbook
Document provided to a patient in an OTP that contains the information he or she should know to understand MAT, program offerings, program structure, and patient limits and privileges, as well as rights and responsibilities of patients and treatment providers.
patient matching. See patient-treatment matching.
patient motivation for change
Relative readiness to modify one's lifestyle and the sincerity and purposefulness of a patient in an OTP toward achieving the goals of MAT.
patient orientation
Planned introduction to the structure, services, offerings, and methods used in an OTP and to patients' and treatment providers' rights and responsibilities within the program.
patient referral. Alternative to providing all necessary treatment services and levels of care at the program site by collaboratively outsourcing some services to other settings and providers. When a patient must obtain comprehensive services in multiple settings, treatment program staff members should arrange the referrals, monitor patient progress, and coordinate care.
patient-treatment matching
Process of individualizing therapeutic resources to patient needs and preferences, ideally by a participatory process involving both the treatment provider and patient. Because many people addicted to opioids have multiple needs, effective patient-treatment matching in an OTP is a three-step process: (1) assessing, (2) selecting the most suitable treatment modality and site, and (3) identifying the most appropriate services.
pharmacology
Science that addresses the origin, nature, chemistry, effects, and uses of medications and drugs.
pharmacotherapy
Treatment of disease with prescribed medications.
preliminary assessment
Basic assessment occurring before admission to a treatment program, in which an individual's eligibility for entry and level of any psychosocial crisis are determined.
prevalence
Number of cases of a disease in a population, either at a point in time (point prevalence) or over a period (period prevalence). Prevalence rate is the fraction of people in a population who have a disease or condition at one time (the numerator of the rate is the number of existing cases of the condition at a specified time and the denominator is the total population).
process-based evaluation
Evaluation of program effectiveness based on compliance with procedural standards. Compare outcome-based evaluation.
psychiatric comorbidity
See co-occurring disorder.
psychoactive drug
A substance that affects the mind, thoughts, feelings, and sometimes behaviors.
psychotherapy. Treatment service provided to patients in a comprehensive opioid treatment program, either directly or by referral, in which a trained therapist evaluates and treats patients for diagnosed psychiatric problems. Compare counseling.
-R-
readmission
Reenrollment of a patient who previously left an opioid treatment program. Readmission usually is preceded by a review of the patient's records to determine whether and how the individual's treatment plan should be modified.
referral
See patient referral.
rehabilitative phase
Phase of MAT in which patients who are stabilized on opioid treatment medication continue to eliminate addictive substances from their lives while gaining control of other major life domains (e.g., medical problems, co-occurring disorders, vocational and educational needs, family circumstances, legal issues).
relapse
Breakdown or setback in a person's attempt to change or modify a particular behavior; an unfolding process in which the resumption of compulsive substance use is the last event in a series of maladaptive responses to internal or external stressors or stimuli.
remission. State in which a mental or physical disorder has been overcome or a disease process halted.
residential treatment
Therapy received within the context of a cooperative living arrangement. Residential treatment programs vary in duration and intensity of services and general philosophy.
retention in treatment
Period during which a patient is able and willing to remain in therapy, which is influenced by a combination of patient and program characteristics. Retention in treatment should be considered the product of a continuing therapeutic relationship between recovering patients and their treatment providers.
-S-
saliva testing
See oral-fluid drug testing.
screening
Process of determining whether a prospective patient has a substance use disorder before admission to treatment. Screening usually involves use of one or more standardized techniques, most of which include a questionnaire or a structured interview. Screening also may include observation of known presenting complaints and symptoms that are indicators of substance use disorders.
sedative
Medication with central nervous system sedating and tranquilizing properties. An example is any of the benzodiazepines. Most sedatives also promote sleep. Overdoses of sedatives can lead to dangerous respiratory depression (slowed breathing).
self-help program
See mutual-help program.
self-medication
Medically unsanctioned use of drugs by a person to relieve any of a variety of problems (e.g., pain, depression).
serum half-life
Time required for the amount of a compound (e.g., an opioid) in blood serum to be halved through metabolism or excretion.
side effect
Consequence (especially an adverse result) other than that for which a drug is used—especially the result produced on a tissue or organ system other than that being targeted.
stabilization (stability)
Process of providing immediate assistance (as with an opioid agonist) to eliminate withdrawal symptoms and drug craving.
stand-alone clinic
Facility that generally offers a comprehensive range of medication and psychosocial services for patients who are opioid addicted, including all levels of care and phases of treatment. Compare hospital-based treatment.
State Authority
Agency (sometimes referred to as a “Single State Agency”) designated by the governor or another official assigned by the governor to exercise the responsibility and authority within a State or territory for governing the treatment of addiction to opioid drugs (adapted from 42 CFR, Part 8 § 2).
stigma
Negative association attached to an activity or condition; a cause of shame or embarrassment. Stigma commonly is associated with opioid addiction and MAT.
stimulant
Agent, drug, or medication that produces stimulation. In this TIP, stimulant usually refers to drugs that stimulate the central nervous system (e.g., amphetamines, cocaine).
substance addiction
See opioid addiction
substance dependence
Dependence. substance use disorder (frequently referred to as substance abuse or dependence
Maladaptive pattern of drug or alcohol use manifested by recurrent, significant adverse consequences related to the repeated use of these drugs or alcohol. The substance-related problem must have persisted and occurred repeatedly during a 12-month period. It can occur sporadically and mainly be associated with social or interpersonal problems, or it can occur regularly and be associated with medical and mental problems, often including tolerance and withdrawal.
supportive-care phase
Phase of MAT in which patients maintain abstinence from substances and continue on maintenance medication while receiving other types of intervention as needed to resume primary responsibility for other aspects of their lives.
-T-
take-home medication
Opioid addiction treatment medication dispensed to patients for unsupervised self-administration.
tapering phase
Phase of MAT in which patients receiving medication maintenance attempt gradually to eliminate their treatment medication (e.g., methadone) while remaining abstinent from illicit substances.
therapeutic alliance.
Joining of patients and their treatment providers in an effective collaboration to assess and treat patients' substance use disorders.
therapeutic community (TC)
Consciously designed social environment or residential treatment setting in which social and group processes are harnessed with treatment intent. A TC promotes abstinence from substance use and seeks to decrease antisocial behavior and effect a global change in lifestyle, including attitudes and values. A TC views substance abuse as a disorder of the whole person, reflecting problems in conduct, attitudes, moods, values, and emotional management. Treatment focuses on drug abstinence, coupled with social and psychological change requiring a multidimensional effort along with intensive mutual help and support.
therapeutic dosage
Combination of amount of medication and frequency and timing of administration that is determined by laboratory analysis, professional observation, or patient self-report to be beneficial to control and ameliorate symptoms of withdrawal from addiction and drug-seeking behavior. Therapeutic dosage levels should be determined by what each patient needs to remain stable.
tolerance
Condition of needing increased amounts of an opioid to achieve intoxication or a desired effect; condition in which continued use of the same amount of a substance has a markedly diminished effect.
treatment barrier
Anything that hinders treatment. Examples include financial problems, language difficulties, ethnic and social attitudes, logistics (caring for children, transportation), and unhelpful patient behaviors (tardiness, missed appointments).
treatment efficacy
Ability of an intervention or medication in expert hands and under ideal circumstances to produce the desired therapeutic effect.
treatment eligibility
Relative qualification of a prospective patient for admission to an OTP according to Federal, State, or third-party payer requirements. In general, Federal guidelines are minimum requirements and restrict admission to individuals who have been demonstrably dependent on opioids for 1 year; however, certain high-risk populations including pregnant women are admitted more quickly.
treatment intensity
Frequency and methods for delivery of therapeutic services. OTPs aim to establish levels of treatment intensity that match patients' needs.
treatment outcomes.
Results of therapy, including decreased use of illicit psychoactive substances, improved physical and emotional health, decreased antisocial activities, and improved social functioning; considered the best indicator of treatment program effectiveness.
treatment plan
Documented therapeutic approach for each patient that outlines attainable short-term goals mutually acceptable to the patient and the OTP and that specifies the services to be provided and their frequency and schedule (adapted from 42 CFR, Part 8 § 2).
treatment retention.See retention in treatment.
12-Step program.
Self-help program requiring mastery of a set of steps to achieve and maintain abstinence, based on the program of Alcoholics Anonymous. Many addiction treatment programs use a 12-Step structure or philosophy as a construct for treatment design.
-U-
urine drug testing
Most common laboratory assessment technique in addiction treatment, which involves analysis of urine samples from patients for the presence or absence of specific drugs. Originally used as a measure of program effectiveness, urine testing now is used to make programmatic decisions, monitor psychoactive substance use, adjust medication dosage, and decide whether a patient is responsible enough to receive take-home medication. Methods of urine testing vary widely.
-V-
voluntary discharge
Discharge from an OTP that is initiated by the patient. Tapering from medication is negotiated among the patient, program physician, and treatment providers.
-W-
withdrawal
Reduction and elimination of substance use. See medically supervised withdrawal, withdrawal syndrome.
withdrawal syndrome (or withdrawal)
Predictable constellation of signs and symptoms after abrupt discontinuation of or rapid decrease in use of a substance that has been used consistently for a period. Signs and symptoms of withdrawal are usually opposite to the direct pharmacological effects of a psychoactive substance
With appropriate credit to:
National Library of Medicine
Monday, October 1, 2007
Random Student Drug Testing
New Study: Schools Infested with Drugs - 2007
A New Study from the National Center on Addiction & Substance Abuse (CASA) suggests that US Schools are infested with drugs.
The survey revealed that at least once a week on their school grounds, 31 percent of high school students (more than four million) and nine percent of middle school students (more than one million) see illegal drugs used, sold, students high and/or drunk.
At least weekly, 17 percent of all high and middle school students (4.4 million) personally see classmates high on drugs at school.
A New Study from the National Center on Addiction & Substance Abuse (CASA) suggests that US Schools are infested with drugs.
The survey revealed that at least once a week on their school grounds, 31 percent of high school students (more than four million) and nine percent of middle school students (more than one million) see illegal drugs used, sold, students high and/or drunk.
At least weekly, 17 percent of all high and middle school students (4.4 million) personally see classmates high on drugs at school.
Tuesday, September 25, 2007
Construction Safety / Drug Testing / Michigan / AGC - Time for Change
The Need for Change: Drug Testing in Construction
Lynn A. Corlett, C.S.P.
We all know that a drug free workplace is a safe workplace and the Michigan union skilled trades and contractors were ahead of their time when the MUST drug screening program was implemented 16 years ago in 1991.
However, times change, the drugs of choice change and the numbers of ways to “beat” the tests have changed.
It’s time again for the union skilled trades and contractors to leap ahead of the national status quo.
Recently the States of Hawaii and Georgia passed legislation to improve safety and reduce workers compensation costs through the implementation of on-site oral fluid / saliva drug screening.
The construction industry played a key role in driving these changes, especially in Hawaii. Organized labor in particular, as well as contractors, owners, and insurers recognized the following:
Drug abuse in the construction sector is as bad, if not worse than ever,
Effective drug testing, especially random drug testing is required to truly manage workplace substance abuse,
Observed specimen collection, convenience, and low cost are mandatory to ensure compliance.
This article attempts to address, from the construction industry’s point of view:
Why should every construction site drug test?
Where do we go from here?
Why drug test?
Simple.
While 10% of employees aged 18 – 49 years abuse drugs (not including alcohol), the construction industry runs 2x-3x this rate.
With over 50% of reportable job-site accidents linked to substance abuse, it’s clear that employee safety and the corporate bottom line are sufficient reasons to implement a drug free workplace program.
A need for change.
Pre-employment drug testing has become an intelligence test.
Access to the internet has made defeating drug tests an easy task. Workers are able to get information on how to “flush” their system; adulterate samples; and there are even products like the Whizinator, which uses synthetic urine undetectable by current drug testing methods, designed to defeat observed urine collection.
Random drug testing, post-incident and reasonable suspicion modes are required components of any comprehensive, effective safety program.
The goal of any drug / alcohol policy is deterrence vs. “catching” employees.
Random testing has consistently demonstrated to be singularly effective in reducing on-the-job substance abuse.
Any effective testing mode must involve direct observation of specimen collection. But observed urine collection is embarrassing and degrading to both the observed and the observer.
Arguably, there are more instances of drug abusers defeating unobserved techniques, such as traditional urine-based testing, than there are “positives”. Just look at nationwide statistics for validation. Seventy-seven percent (77%) of drug abusers are employed.
Furthermore most drug testing (approx. 90%) involves traditional urine laboratory-based pre-employment testing.
Oral fluid worksOral fluid tests are cheaper, faster and easier to use than urinalysis… and unlike urine, can not be easily defeated.
Random testing via on-site oral fluid is fast, provides results within 5-15 minutes, and averages $20 per test. It has the additional advantage of detecting current, vs. historical drug use. Oral fluid tests typically detect from within minutes of consumption up to 2-3 days for most drugs (for THC, the psychoactive ingredient in marijuana, the maximum is 24 hours.). Urine testing can not detect drugs for up to the first several hours and is only an indicator of historical drug use. Furthermore, for THC, detection can go back as far as 30 days. Do you as an employer really care what an otherwise dependable employee does at his/her home on the weekend? Do you even have a right to know?
Also look at the true costs of urine-based random testing. In many cases our current program requires we send our employees off site for random testing. The cost involved includes not only the hourly labor rate, probably $50/hour with benefits, but the productivity loss also. The end result is that a typical off-site urine test is truly costing a job about $300 per test, and the effectiveness is questionable at best.On-site oral fluid based testing works.
Where do we go from here?
Occupational health, safety, and risk management professionals must lead the charge to effect change. We know what truly happens every day on our job sites. At the end of day, we “get it”.
It’s time for us to update our current drug and alcohol free workplace program.
It’s time for the Michigan union skilled trades and contractors to again lead the charge in effecting change.
It’s time to implement oral fluid-based testing techniques at a few “pilot sites” and demonstrate the advantage of effective drug testing programs vs. the status quo.
References:
2006 United States Department of Health – Substance Abuse and Mental Health Agency (SAMSHA) National Survey on Drug Use & Health (NHSDA)- Office of Applied Studies. (2007) Results from the 2006 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 07-4293, NSDUH Series H-32). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Peter N. Cholakis and Roger Bruce (July 2007) Drug Testing in the Workplace – A look at oral fluid-based testing. Professional Safety Journal of the American Society of Safety Engineers, July 2007, 31-36.
Lynn A. Corlett, C.S.P.
We all know that a drug free workplace is a safe workplace and the Michigan union skilled trades and contractors were ahead of their time when the MUST drug screening program was implemented 16 years ago in 1991.
However, times change, the drugs of choice change and the numbers of ways to “beat” the tests have changed.
It’s time again for the union skilled trades and contractors to leap ahead of the national status quo.
Recently the States of Hawaii and Georgia passed legislation to improve safety and reduce workers compensation costs through the implementation of on-site oral fluid / saliva drug screening.
The construction industry played a key role in driving these changes, especially in Hawaii. Organized labor in particular, as well as contractors, owners, and insurers recognized the following:
Drug abuse in the construction sector is as bad, if not worse than ever,
Effective drug testing, especially random drug testing is required to truly manage workplace substance abuse,
Observed specimen collection, convenience, and low cost are mandatory to ensure compliance.
This article attempts to address, from the construction industry’s point of view:
Why should every construction site drug test?
Where do we go from here?
Why drug test?
Simple.
While 10% of employees aged 18 – 49 years abuse drugs (not including alcohol), the construction industry runs 2x-3x this rate.
With over 50% of reportable job-site accidents linked to substance abuse, it’s clear that employee safety and the corporate bottom line are sufficient reasons to implement a drug free workplace program.
A need for change.
Pre-employment drug testing has become an intelligence test.
Access to the internet has made defeating drug tests an easy task. Workers are able to get information on how to “flush” their system; adulterate samples; and there are even products like the Whizinator, which uses synthetic urine undetectable by current drug testing methods, designed to defeat observed urine collection.
Random drug testing, post-incident and reasonable suspicion modes are required components of any comprehensive, effective safety program.
The goal of any drug / alcohol policy is deterrence vs. “catching” employees.
Random testing has consistently demonstrated to be singularly effective in reducing on-the-job substance abuse.
Any effective testing mode must involve direct observation of specimen collection. But observed urine collection is embarrassing and degrading to both the observed and the observer.
Arguably, there are more instances of drug abusers defeating unobserved techniques, such as traditional urine-based testing, than there are “positives”. Just look at nationwide statistics for validation. Seventy-seven percent (77%) of drug abusers are employed.
Furthermore most drug testing (approx. 90%) involves traditional urine laboratory-based pre-employment testing.
Oral fluid worksOral fluid tests are cheaper, faster and easier to use than urinalysis… and unlike urine, can not be easily defeated.
Random testing via on-site oral fluid is fast, provides results within 5-15 minutes, and averages $20 per test. It has the additional advantage of detecting current, vs. historical drug use. Oral fluid tests typically detect from within minutes of consumption up to 2-3 days for most drugs (for THC, the psychoactive ingredient in marijuana, the maximum is 24 hours.). Urine testing can not detect drugs for up to the first several hours and is only an indicator of historical drug use. Furthermore, for THC, detection can go back as far as 30 days. Do you as an employer really care what an otherwise dependable employee does at his/her home on the weekend? Do you even have a right to know?
Also look at the true costs of urine-based random testing. In many cases our current program requires we send our employees off site for random testing. The cost involved includes not only the hourly labor rate, probably $50/hour with benefits, but the productivity loss also. The end result is that a typical off-site urine test is truly costing a job about $300 per test, and the effectiveness is questionable at best.On-site oral fluid based testing works.
Where do we go from here?
Occupational health, safety, and risk management professionals must lead the charge to effect change. We know what truly happens every day on our job sites. At the end of day, we “get it”.
It’s time for us to update our current drug and alcohol free workplace program.
It’s time for the Michigan union skilled trades and contractors to again lead the charge in effecting change.
It’s time to implement oral fluid-based testing techniques at a few “pilot sites” and demonstrate the advantage of effective drug testing programs vs. the status quo.
References:
2006 United States Department of Health – Substance Abuse and Mental Health Agency (SAMSHA) National Survey on Drug Use & Health (NHSDA)- Office of Applied Studies. (2007) Results from the 2006 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 07-4293, NSDUH Series H-32). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Peter N. Cholakis and Roger Bruce (July 2007) Drug Testing in the Workplace – A look at oral fluid-based testing. Professional Safety Journal of the American Society of Safety Engineers, July 2007, 31-36.
Monday, September 24, 2007
Return on Investment - Drug Free Workplace
Return on Investment - Drug Testing
Employee Theft and Fraud
- Average cost Per employee involved: $650
- U.S. Chamber of Commerce estimates 30% of all business failures are due to employee theft and fraud.
- 70% of these crimes are committed by repeat offenders.
- Up to 70% of employee theft is drug related
Cost of Negligent Hiring
- Average cost per incident: $150,000
- Courts are holding companies liable in negligent hiring cases not only for what they knew about a new employee, but also what they should have known.
Employee Turnover
- Average cost per incident: $32,000
- Turnover costs average 1.5 times a person’s yearly salary
Workplace Violence
- Average cost per incident: $1,000,000
- Violence at work is a serious problem, with homicide now the #2 cause of death in the workplace.
- Up to 70% of criminal arrests are drug related
Accidents / Worker's Compensation
- Average cost $10,000 + per incident- 50%+ related to substance abuse
Employee Theft and Fraud
- Average cost Per employee involved: $650
- U.S. Chamber of Commerce estimates 30% of all business failures are due to employee theft and fraud.
- 70% of these crimes are committed by repeat offenders.
- Up to 70% of employee theft is drug related
Cost of Negligent Hiring
- Average cost per incident: $150,000
- Courts are holding companies liable in negligent hiring cases not only for what they knew about a new employee, but also what they should have known.
Employee Turnover
- Average cost per incident: $32,000
- Turnover costs average 1.5 times a person’s yearly salary
Workplace Violence
- Average cost per incident: $1,000,000
- Violence at work is a serious problem, with homicide now the #2 cause of death in the workplace.
- Up to 70% of criminal arrests are drug related
Accidents / Worker's Compensation
- Average cost $10,000 + per incident- 50%+ related to substance abuse
Wednesday, September 19, 2007
Significant Changes to Employee Drug Testing Regulations
Significant Changes to Substance Abuse Testing Laws
Recently the States of Hawaii and Georgia passed legislation in support of workplace drug testing, specifically relative to oral fluid-based/saliva drug on-site screening, and workers compensation premium credits. These actions highlight the need for effective drug-free workplace programs as well convenient drug screening technologies that can be applied consistently, across all modes of testing, especially, however, for random, post-incident, and reasonable suspicion.
It is critical that drug-free workplace safety initiatives are enhanced for the betterment of the American workplace as a whole: employers, employees and families, insurors, etc.
Drug abuse is as bad as it has ever been in our places of employment as well as school systems, and hopefully, these new statutes are a sign of a commitment to change.
Our society cannot continue to sweep America's drug abuse problem under the rug. Abuse of prescription drugs, especially pain-relievers, has superseded marijuana and is is a dangerous trend world-wide.
Arguably, “recreational” marijuana use outside of the workplace may have little, if any, impact to employers or employees, excluding the obvious legal issues. The non-medical use of prescription pain relievers, however, in addition to being potentially lethal, commonly leads to addiction and even escalates to heroin use. The safety and wellness aspect of prescription drug abuse is a very serious issue that must be addressed.
Hawaii
A law that became effective on July 1, 2007, now allows employers to perform on-the-job drug testing using instant, on-site oral fluid/saliva drug screening devices. Oral fluid tests are cheaper, faster and easier to use than urinalysis, hopefully leading to more widespread and consistent drug testing programs.
While it may surprise many, the construction industry and locals unions in particular strongly advocate the new legislation as a means to replace the typical, more expensive laboratory-based urine drug testing. With oral fluid, initial results are available in minutes, and observing the sample collection mitigates the prevalent practice of drug abusers “beating the test” via sample adulteration or substitution. Urine laboratory testing typically required the expensive practice of sending employees off-site to a clinic or laboratory, a process that takes at least 3-4 hours with results available for 24-48 hours. As noted by Lt. Governor Aiona of Hawaii, "Drug and alcohol abuse remain a problem in Hawaii's workforce. The law will go a long way towards helping to promote a drug-free workplace. This measure provides a cost effective on-the-job alternative to laboratory tests that can be costly and difficult to schedule."According to the U.S. Department of Labor, drug or alcohol abuse is involved in the majority of fatal accidents in the workplace. These laws represent an effort by the State Government to make the workplace safer for everyone.Although the new law permitting oral drug testing was effective on July 1, 2007, in many cases collective bargaining agreements will have to be updated before companies can start using the non-FDA approved tests. This procedure isn't expected to take long, however, since the unions - as well as management and the State Government - are in favor of the new law. According to union sources, they welcome the improved safety and working conditions that the tests will introduce.
One representative of the Pacific Resource Partnership, an alliance between contractors and the Carpenters Union Local 745, said construction workers and the industry pushed for the new tests as a way to decrease costs and save time while keeping job sites safe."This is something that I think is going to be a great asset for employers, especially in the construction industry where public safety is a huge factor," said Lt. Governor Aiona.
Georgia
In a similar bill, Governor Perdue of Georgia recently signed Senate Bill 96 into law which provides the option for companies throughout Georgia to drug test employees using an on-site rapid result oral fluid/saliva devices.
As in Hawaii, initial qualitative results are available in minutes, and if “negative” an employee goes back to work. Any “non-negative” (preliminary positive) results are sent to a lab for a GC/MS or LC/MS/MS quantitative analytical testing prior to substantive employers’ actions such as mandatory enrollment in employee assistance programs/counseling, removal from safety-sensitive duties, and/or suspension.
Per Governor Perdue, the bill which overwhelmingly passed the State Senate and House of Representatives, "had the strong support of the Georgia Chamber of Commerce and many other advocates of safe and drug-free workplaces that protect not only business owners, but employees and consumers as well.Companies using on-site oral fluid/saliva screens will now receive a 7.5 percent reduction in their worker's compensation insurance premiums. Summary
Drug testing in the workplace is not only legal, it may very well be part of an employer’s responsibility to provide a safe workplace for employees. The United Supreme Court has ruled that drug testing, including random drug testing, is legal. Furthermore, per the Department of Labor, OSHA, it is an employer’s responsibility to provide a safe workplace for all employees.
Assuming a comprehensive safety program is in place, a safe workplace is simply not possible without also maintaining a comprehensive drug-free workplace program inclusive of employee education, drug testing, and employee assistance/counseling.
Regardless of the specimen type used such as oral fluid/saliva, urine, or hair, it is critical that specimen collection be directly observed, and that drug testing is done on a regular basis. This includes; random, post-incident, reasonable suspicion, and return-to-duty mode. Pre-employment testing, while currently the most widely practiced of modes, is referred to by many experts as an “intelligence test”, and should not be relied upon exclusively.
When combined with education, and employee assistance programs, comprehensive drug-free workplace programs consistently result in a reduction in reportable site accidents of up to 50% or more, as well as multiple other safety and “bottom-line” benefits.
Recently the States of Hawaii and Georgia passed legislation in support of workplace drug testing, specifically relative to oral fluid-based/saliva drug on-site screening, and workers compensation premium credits. These actions highlight the need for effective drug-free workplace programs as well convenient drug screening technologies that can be applied consistently, across all modes of testing, especially, however, for random, post-incident, and reasonable suspicion.
It is critical that drug-free workplace safety initiatives are enhanced for the betterment of the American workplace as a whole: employers, employees and families, insurors, etc.
Drug abuse is as bad as it has ever been in our places of employment as well as school systems, and hopefully, these new statutes are a sign of a commitment to change.
Our society cannot continue to sweep America's drug abuse problem under the rug. Abuse of prescription drugs, especially pain-relievers, has superseded marijuana and is is a dangerous trend world-wide.
Arguably, “recreational” marijuana use outside of the workplace may have little, if any, impact to employers or employees, excluding the obvious legal issues. The non-medical use of prescription pain relievers, however, in addition to being potentially lethal, commonly leads to addiction and even escalates to heroin use. The safety and wellness aspect of prescription drug abuse is a very serious issue that must be addressed.
Hawaii
A law that became effective on July 1, 2007, now allows employers to perform on-the-job drug testing using instant, on-site oral fluid/saliva drug screening devices. Oral fluid tests are cheaper, faster and easier to use than urinalysis, hopefully leading to more widespread and consistent drug testing programs.
While it may surprise many, the construction industry and locals unions in particular strongly advocate the new legislation as a means to replace the typical, more expensive laboratory-based urine drug testing. With oral fluid, initial results are available in minutes, and observing the sample collection mitigates the prevalent practice of drug abusers “beating the test” via sample adulteration or substitution. Urine laboratory testing typically required the expensive practice of sending employees off-site to a clinic or laboratory, a process that takes at least 3-4 hours with results available for 24-48 hours. As noted by Lt. Governor Aiona of Hawaii, "Drug and alcohol abuse remain a problem in Hawaii's workforce. The law will go a long way towards helping to promote a drug-free workplace. This measure provides a cost effective on-the-job alternative to laboratory tests that can be costly and difficult to schedule."According to the U.S. Department of Labor, drug or alcohol abuse is involved in the majority of fatal accidents in the workplace. These laws represent an effort by the State Government to make the workplace safer for everyone.Although the new law permitting oral drug testing was effective on July 1, 2007, in many cases collective bargaining agreements will have to be updated before companies can start using the non-FDA approved tests. This procedure isn't expected to take long, however, since the unions - as well as management and the State Government - are in favor of the new law. According to union sources, they welcome the improved safety and working conditions that the tests will introduce.
One representative of the Pacific Resource Partnership, an alliance between contractors and the Carpenters Union Local 745, said construction workers and the industry pushed for the new tests as a way to decrease costs and save time while keeping job sites safe."This is something that I think is going to be a great asset for employers, especially in the construction industry where public safety is a huge factor," said Lt. Governor Aiona.
Georgia
In a similar bill, Governor Perdue of Georgia recently signed Senate Bill 96 into law which provides the option for companies throughout Georgia to drug test employees using an on-site rapid result oral fluid/saliva devices.
As in Hawaii, initial qualitative results are available in minutes, and if “negative” an employee goes back to work. Any “non-negative” (preliminary positive) results are sent to a lab for a GC/MS or LC/MS/MS quantitative analytical testing prior to substantive employers’ actions such as mandatory enrollment in employee assistance programs/counseling, removal from safety-sensitive duties, and/or suspension.
Per Governor Perdue, the bill which overwhelmingly passed the State Senate and House of Representatives, "had the strong support of the Georgia Chamber of Commerce and many other advocates of safe and drug-free workplaces that protect not only business owners, but employees and consumers as well.Companies using on-site oral fluid/saliva screens will now receive a 7.5 percent reduction in their worker's compensation insurance premiums. Summary
Drug testing in the workplace is not only legal, it may very well be part of an employer’s responsibility to provide a safe workplace for employees. The United Supreme Court has ruled that drug testing, including random drug testing, is legal. Furthermore, per the Department of Labor, OSHA, it is an employer’s responsibility to provide a safe workplace for all employees.
Assuming a comprehensive safety program is in place, a safe workplace is simply not possible without also maintaining a comprehensive drug-free workplace program inclusive of employee education, drug testing, and employee assistance/counseling.
Regardless of the specimen type used such as oral fluid/saliva, urine, or hair, it is critical that specimen collection be directly observed, and that drug testing is done on a regular basis. This includes; random, post-incident, reasonable suspicion, and return-to-duty mode. Pre-employment testing, while currently the most widely practiced of modes, is referred to by many experts as an “intelligence test”, and should not be relied upon exclusively.
When combined with education, and employee assistance programs, comprehensive drug-free workplace programs consistently result in a reduction in reportable site accidents of up to 50% or more, as well as multiple other safety and “bottom-line” benefits.
Thursday, September 13, 2007
False Negatives False Positives in Drug Testing
False Negatives & False Positives
Qualitative Results
A qualitative drug test is one that provides a dichotomous result, that is, it indicates whether a sample is positive or negative for a specified drug. However, there are four possible results of a qualitative drug test.
A true-positive result occurs when the test correctly identifies the presence of a drug in the sample taken.
A false-positive result is one where the test incorrectly detects the presence of a drug where in fact no drug is present.
A false-negative result is one where the test fails to detect the presence of a drug when it is in fact present.
A true-negative result occurs when a test correctly detects the absense of a drug.
Interpreting a Positive Test Result
A positive result indicates that the specific drug (or class of drug) is present at or above the designated cut-off level. Typically, the cut-off concentration is set to the lowest concentration the drug can be reliably detected following consumption. It considers environmental and analytical variability caused by such factors as passive contamination/ingestion, technological limits, etc.
False-positives resulting from qualitative screening.
A false-positive result can occur when a benign substance in the biological sample mimics the chemical effect of the targeted substance on the test. The test indicates a positive result even though the targeted drug was absent. Such results have reportedly occurred after ingestion of antihistamines, certain anti- inflammatory drugs, cold and flu medications, and poppy seeds (Selavka, 1991).
Although levels are generally low, it does highlight the necessity of appropriate confirmatory testing with parent / metabolite quantification to identify and safeguard against this.
Interpreting a Negative Test Result
In the majority of cases a negative result indicates that the parent drug (typcially the active ingredient) and / or its metabolites are absent in the biological sample. It does not mean that the person has not used the substance in the days or weeks prior to testing. The amount of drug present in the sample at the time of sample collection, and thus whether a positive result is obtained, is determined by a number of factors which include: the cut-off level used; the testing schedule employed; the biological sample analyzed; when the drug was ingested; the amount of drug ingested; the form in which it was ingested; and physical and pharmacological characteristics of the user.
False-negatives
When an initial screen result in negative and (1.) the individual ingests a drug and the concentration of the drug in the sample is at our above the cut-off, or (2.) the individual ingests a drug and the concentration of of the sample is below the the cut-off due to sample adulteration or substitution, the result referred to as a “false-negative”.
Relative to urinalysis, there are a number of actions an individual can take, to increase the likelihood of a false-negative result. An individual can adulterate the specimen via dilution by drinking excessive amounts of water (in vivo adulteration), or by adding water or chemicals that will affect the test (in vitro adulteration) (Coleman & Baselt, 1997). Hair testing may be susceptible to excessive washing (Rohrich, Zorntlein, Potsch, et al., 2000), bleaching (Yegles, Marson & Wennig, 2000) and other cosmetic hair treatment (Skopp, Potsch & Moeller, 1997). There are no currently proven methods to adulterate or substitute oral fluid.
Quantitative Results
Quantitative drug testing involves the determination of the specific concentrations of a parent drug and/or its metabolite(s) in a sample, typically via GC/MS and LC/MS/MS. In addition to confirmatory testing of qualitative screening results, quantitative results quantitative results using blood or oral fluid / saliva specimens can provide additional information regarding the quantity and frequency of drug use (Cone, 1997).
Blood and/or oral fluid / saliva may also be useful when establishing impairment levels for certain drug classes.
Urine and hair specimens are generally considered effective for historical use only. With knowledge of the drug’s pharmacokinetic parameters, including its half-life, an estimate of the frequency of new drug use can be obtained using quantitative analysis (Cone, 1997, Huestis and Cone 1998).
The Physiology of Urine Production
Urine is produced continuously by the kidneys and may be considered an ultrafiltrate of blood. During urine production the kidneys reabsorb essential substances. Excess water and waste products, such as urea, organic substances and inorganic substances, are eliminated from the body. Parent drugs (typically the active ingredient) are often present in urine in very low concentrations or not detected at all. Therefore distinguishing between codeine, heroin and morphine use, for example, can be difficult. Furthermore, inter-subject variations in urine drug concentrations, even after similar dosing, is high.Absorption into urine is usually slow when a drug is orally administered and excretion may be delayed for several hours (approximately 6-9 hours) .Generally, a urine specimen will contain the highest concentration of parent drug and metabolite at this time period. As drug elimination usually occurs at an exponential rate, for most illicit drugs a dose will be eliminated almost completely within 48 hours. A number of factors influence detection times including the quantity of drug administered, parent drug and metabolite half- life, cut-off level used, and a number of physiological factors. It is also noted that for many of drugs, frequent, multiple dosing over extended periods of time can cause the drug to accumulate in the body resulting in significantly extended detection times.The
Physiology of Oral Fluid
Salivary gland is a term used to include any tissue that normally discharges a secretary product into the oral cavity. Thus, oral fluid refers to the mixture of fluid in the oral cavity. Saliva is a complex aqueous fluid (99% water) containing electrolytes (principally sodium,potassium, chloride and bicarbonate), proteins (mostly enzymes, including amylase) and muncin (Kidwell, Holland & Athanaselis, 1998). The mucin gives oral fluid its sticky character. Saliva also contains cell and food debris and oral microorganisms. The composition and production of oral fluid is determined by the relative contribution of the different glands, which in turn is dependant on a variety of factors including nutritional and emotional state, sex, age, season of the year, time of day, and a variety of diseases and pharmacological agents (Höld, 1996; United Nations, 1998)
The three major salivary glands are: (1) the parotid, at the top of the mouth, (2) the submandibular, at the base of the tongue, and (3) the sublingual, at the sides of the oral cavity. The parotid gland, responsible for about 25% of the saliva produced, excretes saliva derived primarily from blood plasma (serous fluid); the submandibular and sublingual glands excrete both serous fluid and mucin and contribute approximately 71% and 4% respectively (Kidwell, Holland & Athanaselis, 1998). The volume of saliva produced by an adult ranges from 500 to 1500 ml per day. Unstimulated saliva has a pH range between 5.6 and 7. Stimulation increases the pH to a maximum of 8 (Kidwell, Holland & Athanaselis, 1998).A thin layer of epithelial cells separates the salivary ducts from the systemic blood circulation (capillaries). The lipid membrane of these cells determines which molecules may be transferred from blood plasma into oral fluid. Three routes have been identified that may transport a drug across the lipid membrane; these include active transport (secretion), passive diffusion through the membrane across a concentration gradient, and diffusion through pores in the membrane (ultrafiltration) (Höld, de Boer, Zuidema & Maes, 1996,United Nations, 1998). Some molecules with a low molecular mass (i.e. ethanol) may diffuse through the water-filled pores in the membrane. Other small molecules are primarily transported through secretion. For larger molecules (most drugs of abuse), passive diffusion across a concentration gradient is thought to be the major factor in transport (Höld, de Boer, Zuidema & Maes, 1996; Huestis & Cone, 1998).
Equilibrium occurs between plasma and saliva.
In plasma a large proportion of a drug is bound to proteins. Drug concentrations in oral vary with the free fraction of drug in plasma, and therefore mimic concentrations found in blood (Cone, 1993). Interpretation of Drug Concentrations in Saliva has been shown to be a suitable matrix for the detection of drugs of abuse, specifically cocaine and benzoylecgonine (e.g. Cone, 1993; Schramm, Craig, Smith, et al., 1993), heroin, 6-MAM and morphine (e.g. Goldberger, Darwin, Grant, et al., 1993), codeine (in Huestis & Cone, 1998b), methadone (e.g. Wolff, 1991) and amphetamines (Cone, 1993). Cannabis use is somewhat more difficult to detect in saliva though it has been shown to be possible (e.g. Menkes, Howard, Spears, et al., 1991).
Saliva drug concentrations generally correlate well with the free fraction of drug in blood (Cone, 1993; Kidwell, Holland & Athanaselis, 1998).
Saliva can be used to provide both qualitative and quantitative information on the drug status of an individual undergoing testing for all drugs of abuse reviewed (Cone, 1993).
Much research into saliva testing has examined its utility as an alternative test matrix to blood and urine.
Friday, September 7, 2007
THC Detection in Oral Fluid / Saliva
THC Detection
First and forement, devices / techniques must screen for THC-delta-9 in oral fluid NOT THC-COOH and/or delta-11, etc. The latter is a metabolite found only in urine at any level that can be commonly detected, the former is the active ingreadient of marijuna and found in oral fluid.Detection of THC-delta-9 in oral fluid has repeatedly been demonstrated to be possible from connsumption... up to 24 hours post consumption.The following is one of several references available on this topic:Relationship of (9)-tetrahydrocannabinol concentrations in oral fluid and plasma after controlled administration of smoked cannabis byHuestis MA, Cone EJ.Intramural Research Program,National Institute on Drug Abuse, National Institutes of Health,Baltimore, Maryland 21224. J Anal Toxicol. 2004 Sep;28(6):394-9ABSTRACTUnderstanding the relationship of (9)-tetrahydrocannabinol (THC) concentrations in oral fluid and plasma is important in interpretation of oral fluid test results. Current evidence suggests that THC is deposited in the oral cavity during cannabis smoking. This "depot" represents the primary or sole source of THC found when oral fluid is collected and analyzed. In this research, oral fluid and plasma specimens were collected from six subjects following smoking of cannabis cigarettes containing 1.75% and 3.55% THC. There was at least one week between each cannabis administration. Plasma specimens were analyzed by gas chromatography-mass spectrometry (GC-MS) and paired oral fluid specimens were analyzed by radioimmunoassay (RIA). In addition, one individual's oral fluid specimens were also analyzed by GC-MS. These data are unique in that they represent simultaneous or near simultaneous collection of oral fluid and plasma specimens in subjects following controlled cannabis dosing. The first oral fluid specimen, collected from one subject at 0.2 h following initiation of smoking, contained a THC concentration of 5800 ng/mL (GC-MS). The similarity in oral fluid and plasma THC concentrations following the dissipation of the initial "contamination" indicates the likelihood of a physiological link between these specimens. Recent studies have shown that sublingual or transmucosal administration of pure THC results in direct absorption of intact THC into the bloodstream, thereby bypassing the gastrointestinal tract. The current study demonstrates that THC is deposited in the oral cavity and remains for up to 24 h following cannabis smoking. The decline in THC oral fluid concentration over this time suggests that there may be absorption of THC into blood as previously shown with pure THC. Passive cannabis exposure studies appear to indicate that positive oral fluid tests for THC can occur shortly after cannabis smoke exposure, but results were negative within 1 h. Consequently, when very recent passive exposure to cannabis smoke can be ruled out, it is concluded that a positive oral fluid test provides credible evidence of active cannabis use.
First and forement, devices / techniques must screen for THC-delta-9 in oral fluid NOT THC-COOH and/or delta-11, etc. The latter is a metabolite found only in urine at any level that can be commonly detected, the former is the active ingreadient of marijuna and found in oral fluid.Detection of THC-delta-9 in oral fluid has repeatedly been demonstrated to be possible from connsumption... up to 24 hours post consumption.The following is one of several references available on this topic:Relationship of (9)-tetrahydrocannabinol concentrations in oral fluid and plasma after controlled administration of smoked cannabis byHuestis MA, Cone EJ.Intramural Research Program,National Institute on Drug Abuse, National Institutes of Health,Baltimore, Maryland 21224. J Anal Toxicol. 2004 Sep;28(6):394-9ABSTRACTUnderstanding the relationship of (9)-tetrahydrocannabinol (THC) concentrations in oral fluid and plasma is important in interpretation of oral fluid test results. Current evidence suggests that THC is deposited in the oral cavity during cannabis smoking. This "depot" represents the primary or sole source of THC found when oral fluid is collected and analyzed. In this research, oral fluid and plasma specimens were collected from six subjects following smoking of cannabis cigarettes containing 1.75% and 3.55% THC. There was at least one week between each cannabis administration. Plasma specimens were analyzed by gas chromatography-mass spectrometry (GC-MS) and paired oral fluid specimens were analyzed by radioimmunoassay (RIA). In addition, one individual's oral fluid specimens were also analyzed by GC-MS. These data are unique in that they represent simultaneous or near simultaneous collection of oral fluid and plasma specimens in subjects following controlled cannabis dosing. The first oral fluid specimen, collected from one subject at 0.2 h following initiation of smoking, contained a THC concentration of 5800 ng/mL (GC-MS). The similarity in oral fluid and plasma THC concentrations following the dissipation of the initial "contamination" indicates the likelihood of a physiological link between these specimens. Recent studies have shown that sublingual or transmucosal administration of pure THC results in direct absorption of intact THC into the bloodstream, thereby bypassing the gastrointestinal tract. The current study demonstrates that THC is deposited in the oral cavity and remains for up to 24 h following cannabis smoking. The decline in THC oral fluid concentration over this time suggests that there may be absorption of THC into blood as previously shown with pure THC. Passive cannabis exposure studies appear to indicate that positive oral fluid tests for THC can occur shortly after cannabis smoke exposure, but results were negative within 1 h. Consequently, when very recent passive exposure to cannabis smoke can be ruled out, it is concluded that a positive oral fluid test provides credible evidence of active cannabis use.
Detection Windows vs. Specimen Type
The primary goals of any drug-free workplace policy is to deter substance abuse. In order to accomplish this end, a combination of education, drug testing, and employee assistance/counseling is required.
Relative to the drug test the following elements must be present:
1. Ability to detect current / on-the-job drug abuse.
2. Convenience for both donor and test administrator.
3. Observed specimen collection.
Only oral fluid / saliva meets all three objectives.
Urine can only detect historical drug abuse and there is no relationship between drug metabolite concentration and impairment and/or time drug was ingested. Observed collection is not possible in most workplace settings.
Hair is the best method for detecting historical drug abuse, and allows for observed collection. However, is only suitable for pre-employment testing as it can not detect drug consumption within the past seven days.
Oral fluid can detect drug consumption within minutes of consumption, up to 2-3 days for many drugs. THC detection is limited to approximately 24 hours, however, the impairment period for marijuana is generally reported to be one hour (two hour maximum).
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