By Anthony Vecchione
Collecting a urine specimen has been the gold standard for drug testing in the workplace. But that could all change.
In May, the Department of Health and Human Services (HHS) proposed to establish scientific and technical guidelines for the inclusion of oral fluid specimens in the Mandatory Guidelines for Federal Workplace Drug Testing Programs. To read the guidelines, go to http://www.gpo.gov/fdsys/pkg/ FR-2015-05-15/pdf/2015-11523.pdf
This proposed revision to the guidelines would allow federal executive branch agencies to collect and test an oral fluid specimen as part of their drug testing programs.
Using data obtained from the Federal Workplace Drug Testing Programs and HHS-certified laboratories: “HHS estimates the number of specimens tested annually for federal agencies to be about 150,000. HHS projects that approximately 7% (or 10,500) of the 150,000 annual specimens tested per year will be oral fluid specimens.”
The posted rule states that “these guidelines provide flexibility for federal agency workplace drug testing programs to address testing needs and remove the requirement to collect only a urine specimen, which has existed since the guidelines were first published in 1988.”
How does the occupational health community feel about the proposed addition of oral testing to the mix?
In a letter to The Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of HHS, The American College of Occupational and Environmental Medicine, (ACOEM), said having alternatives to traditional urine specimen testing benefits everyone.: “We are in agreement that the time has come for alternative specimen testing and the advancements in science regarding oral fluid testing are currently at a level on par with urine testing.”
Douglas Martin, M.D., chair, of ACOEM Medical Review Officers Section, said one of the main drivers of oral fluid testing is the issue of “nefarious donation.”
Dr. Martin, medical director of Unity Point Occupational Medicine in Sioux City, Iowa, said that in essence oral fluid and hair automatically make all tests “observed collections.”
“We spend a fair amount of time as medical review officers (MROs) dealing with the results that come back from the lab for urine samples that are adulterated or substituted or [have experienced] some sort of tampering. Theoretically, oral fluid and hair testing [removes that possibility],” Dr. Martin said.
Kent Peterson M.D., president of Occupational Health Strategies, Charlottesville, VA said that as oral fluid testing becomes more prevalent, the costs will lower, and become comparable to urine.
“One advantage of oral fluid testing is the ease of collection. And you can directly witness the person putting a swab in their mouth, so there is not the same opportunity for trying to beat the drug test,” Dr. Peterson said.
The federal government, Dr. Peterson asserted, has looked at the science of oral fluid, and saliva testing and determined the validation of that test in comparison to urine is very close.
“Initially, oral fluid testing was much less sensitive to marijuana. But that’s [changed] along with the sensitivity of the test. The results are very comparable [to urine tests]. What they measure is the use of drugs over a two-to-five-day period,” Dr. Peterson said.
Many employers, Dr. Peterson said, are more interested in what somebody has done in the last five days than the last two weeks.
While many occupational health experts agree that the addition of oral fluid testing is likely, some believe that the transition will be more gradual.
“I think we will have a combination of both; we will continue with the urine collection with companies and as we do more saliva testing, that method will increase,” said Mike Schmidt, NAOHP Board President and director of operations at St. Luke’s Occupational Health Services in Sioux City, IA.
Danielle Anderson, regional director of operations at WorkNet Occupational Medicine in Eastern, PA, said that when it comes to the subject of urine versus oral testing, the process operationally is likely to be easier. “Because the process of doing saliva testing is an easier, cleaner process, I am excited they are moving in that direction,” Anderson said.
Ms. Anderson added that the process of collecting a urine specimen is somewhat antiquated, as safeguards have been created to ensure you are collecting a specimen from the actual donor (e.g., temperature checks, visual color checks, and odor checks). “And Dr. Douglas Martin Occupational Medicine Prepares for Sea Change in Drug Testing Methods Dr. Kent Peterson 9 The paperwork is also antiquated as it is carbon-copied forms that are physically in the clinic. Given the technology available in 2015, it would be more efficient to move towards a technology-based chain of custody,” Ms. Anderson said.
Regarding privacy, Ms. Anderson pointed out that the process of urine collection requires the donor to use a restroom out of the vision of the certified and trained collector. Saliva and hair do not require the collection process to separate the donor from the collector.
Some experts point out that despite the positives associated with oral fluid testing, there is a downside. “When saliva instant testing came about – when I was researching back in the mid-2000s – the first thing that came up was [information on] how to beat the drug test,” said Rita M. Lebo, Director, WorkNet Drug and Alcohol Service. “You put Vaseline in your mouth where your salivary glands are under your tongue and it blocks the test.”
Hair Testing
For about a decade, there has been a strong commercial promotion of hair testing by those who have patented some techniques. Dr. Peterson noted that among non-federally regulated professions, some employers have adopted hair testing.
“Hair testing is more expensive than urine testing and it has some problems,” Dr. Petersen said. “For example, hair that is dark means that the person deposits melanin pigment in the hair. They also deposit drug metabolites in the hair. Hair that is white means the body is not depositing melanin in the hair; and it also does not deposit as many drug metabolites.”
This means, according to Dr. Peterson, if you have white hair a hair test is far less likely to pick up drugs. This raises a question about whether hair testing discriminates against people with dark hair and favors those with white and red hair.
“The advantage of hair testing is that it has a much longer window of detection. So if you’re taking a three cm segment of hair starting from the base of the scalp, that can detect regular use over a prolonged period of about 90 days. (An average of one centimeter per month of growth),” Dr. Peterson said.
Many employers find that hair testing for pre-employment drug tests makes sense because it picks up the regular habitual use of a drug. On the other hand, if a person has just used it once or twice recently, their hair is not going to reveal much.
Hair testing is two to three times more expensive than urine. Because of differences in what is being tested, you can have positive urine and negative hair or positive hair and negative urine. However, according to industry experts, both tests can be valid.
“If hair testing is proposed for federally-regulated workplace testing, I think there’s going to be a lot of objection in terms of the ways that hair products might be adulterated and the question of discrimination. Congress has recently considered a bill to authorize this, and I have seen a number of letters strongly opposing workplace hair testing,” Dr. Peterson said.
Cost Differences
Although hair testing is generally more expensive than urine and oral fluid testing, industry insiders contend that market forces will change that.
“What I have seen is a competitive drill-down on the cost with respect to urine testing because of competitive forces. I think you will find the same thing happen with oral fluid testing; more expensive when it first comes out, but as time goes on it will get to the level where it’s on par with the cost of a urine test,” Dr. Martin said.
Dr. Martin pointed out that the same thing happened with urine testing years ago when the federal Workplace Drug Act became law. Federal urine tests were expensive. There was pushback and as time went on competitive forces drove the cost down.
(BAT) Breath Alcohol Test
Experts agree that the BAT remains a very accurate test for alcohol. This evidentiary test examines oral fluid by inserting a swab into the mouth. A positive oral fluid test for alcohol must be confirmed with an evidentiary breath test within 15 minutes.
“Breath Alcohol technology has been around for a long time, it has been well established scientifically. There isn’t a push to do anything different. It’s non-invasive and simple to do. I don’t see that changing,” said Dr. Martin.
Illicit Drug Positivity Rate Increases In Workplace Testing
While occupational health professionals prepare for the transition from urine to oral fluid testing, they are also keeping an eye on the rising number of American workers testing positive for illicit drug use.
According to data from the Quest Diagnostics Drug Testing Index (DTI), released in June, the number of American workers testing positive for illicit drugs like marijuana, cocaine, and methamphetamine has increased for the second consecutive year.[See table 1]
Results from the DTI show the positivity rate for 6.6 million urine drug tests in the general U.S. workforce increased by 9.3% from 2013 to 2014; that is, from 4.3 to 4.7% in that year. According to the data, 2013 was the first year since 2003 in which the overall positivity rate for urine drug tests increased in the general U.S. workforce. Overall positivity for oral fluid and hair drug tests, representing approximately 1.1 million tests, also rose in that time period.
Analysis by Quest Diagnostics suggests that public and private employers might want to consider revisiting existing substance abuse policies to ensure that they are taking the necessary precautions to protect their workplace, employees, and businesses.
Barry Sample, PhD, director of science and technology at Quest Diagnostics, said employers need to be cognizant of several things:
“They should not get complacent – regarding drug testing. While we have been reporting on flat or declining positivity rates for quite some time we have found this uptick that we are [now] reporting. It’s a broad uptick across multiple illicit drugs,” Mr. Sample said.
Mr. Sample added that the data points out that employers need to remain vigilant in their drug testing programs and not imagine drug use is going down or even staying at the current level.
“They need to be sensitive to the potential regulatory or statutory changes in several states with respect to medical marijuana use and recreational use. And while employers in states with recreational use statutes can still test for marijuana and make adverse employment decisions on the basis of the results of those tests,” Mr. Sample said. Employers need to keep their finger on the pulse of what the case law is doing and what the regulations are.
[See Medical Marijuana in the Workplace: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410963/
The Future
Key leaders in the occupational health community agree that the transition to oral fluid testing is forthcoming. According to Dr. Martin, “There is no one I have talked to in the medical review officer world who doesn’t think it’s a go.”
QuestDiagnostics.com/DTI Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third-party marks – ® and ™ – are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved. 6/3/2015
