People with substance use disorders often do not self-disclose substance use reliably. Studies conducted in substance use treatment, primary medical care and emergency room settings have reported that between 25% and 85% of individuals testing positive for illicit drugs or alcohol denied recent usage (Bagley et al., 2018; Chen et al., 2006; Harris et al., 2008; Hindin et al., 1994; Magura & Kang, 1997; Morral et al., 2000; Nordeck et al., 2020; Peters et al., 2015; Sharma et al., 2016; Tassiopoulos et al., 2004). Clinical guidelines promulgated by leading professional organizations and government agencies, including the American Society of Addiction Medicine (ASAM, 2017), National Institute of Drug Abuse (NIDA, 2018), Substance Abuse and Mental Health Services Administration (SAMHSA, 2012) and the National Association of Drug Court Professionals (NADCP, 2015), provide that programs should perform biological testing of drug and alcohol use to verify patient self-report, deliver objective feedback to patients about the nature and severity of their illness, monitor treatment progress and reinforce abstinence.
Every element of the Averhealth solution incorporates evidence-based practices, positioning your program and your clients for the best possible outcome.
Testing Frequency
Virtually all studies examining the frequency of drug and alcohol testing have been conducted in criminal justice settings, including probation, parole, drug courts and DUI courts. Results reveal that greater frequency of testing is correlated with significantly better outcomes in terms of higher program completion rates and lower illicit substance use and criminal recidivism (Cadwallader, 2017; Gottfredson et al., 2007; Kinlock et al., 2013 Kleinpeter et al., 2010). In focus groups, drug court patients commonly identify frequent drug and alcohol testing as being among the most influential factors for success in the program (Gallagher et al., 2015; Goldkamp et al., 2002; Saum et al., 2002; Turner et al., 1999; Wolfer, 2006).
Evidence suggests twice-weekly urine testing may be required for persons with severe substance use disorders in the justice system. A multisite study of sixty-nine drug courts found that programs performing urine testing at least twice per week during the first several months of treatment were 38% more effective at reducing crime and 61% more cost-effective than programs performing urine testing less frequently (Carey et al., 2012). A large-scale study of probationers charged with drug-related offenses determined that once-weekly urine testing detected only about one-third (35%) of instances of drug use whereas twice-weekly testing detected more than 80% of drug use (Kleiman et al., 2003). Comparable information is unavailable for other types of tests (e.g., breath, sweat, hair or transdermal tests) and for non-criminal justice populations.
Testing Duration
Many clinicians believe the accuracy of self-report increases over the course of treatment as a therapeutic alliance develops between clinician and patient (Jarvis et al., 2017; Srebnik et al., 2014). This explains, in part, why many treatment programs decrease the frequency of drug and alcohol testing over time. Contrary evidence, however, raises serious concerns about this practice. Studies conducted in the 1990s determined that under-reporting of substance use worsened after patients had been in treatment for several months or had completed treatment (Wish et al., 1997). More recent studies have concluded that patients may find it harder to acknowledge substance use after a therapeutic alliance has developed (Davis et al., 2014; Nirenberg et al., 2013). The longer patients are in treatment, the more staff come to expect and insist upon abstinence. This may lead to greater feelings of shame or anxiety on the part of patients, or greater disappointment on the part of staff, when those expectations are violated.
Reducing the frequency of testing prematurely may increase the odds of relapse. Most programs decrease the intensity of other treatment and supervision services (e.g., counseling, probation sessions, court hearings) as patients make progress in the program. With these service reductions comes an increasing risk of relapse or behavioral setback. If drug and alcohol testing is reduced at the same time, then just as the risk of relapse is increasing, the likelihood of detecting it is decreasing. Clinical progress may stagnate or reverse for weeks or months before staff become aware of the problem. For this reason, best practice standards for drug courts require programs to continue drug and alcohol testing unabated until after all other service adjustments have been made to ensure that relapse does not occur (NADCP, 2015).
Random Testing
Clinical consensus favors random testing over prescheduled testing (ASAM, 2017) and random testing is standard practice in the criminal justice system (Auerbach, 2007; Carver 2004; Cary, 2011; Harrell & Kleiman, 2002). A few studies have reported that random testing elicited significantly higher rates of positive drug tests than prescheduled testing, suggesting that some patients may evade detection if they have advance notice of when testing will occur (ASAM, 2017; Harrison, 1997). Patients may, for example, time their usage between appointments if they know their testing schedule ahead of time (McIntire & Lessenger, 2007). For this reason, many treatment programs prescribe random testing.
No information is available on whether testing must remain random throughout the course of treatment or whether the impact of randomness may differ for different testing frequencies. If, for example, patients are drug tested three times per week, there may be less need for randomization because the probability of detection is already high.