Portal de Periódicos da CAPES

The Law of Unintended Consequences Can Never Be Repealed: The Hazards of Random Urine Drug Screening of Anesthesia Providers

2017; Lippincott Williams & Wilkins; Volume: 124; Issue: 5 Linguagem: Inglês

10.1213/ane.0000000000001972

1526-7598

Keith H. Berge, Brian P. McGlinch,

Cardiac, Anesthesia and Surgical Outcomes

In the current issue of Anesthesia & Analgesia, Rice et al1 provide a special article that revisits compulsory random urine drug screening (RUDS) in anesthesia providers, an issue that has long been contentious among anesthesiologists. The authors posit that, in this population, widespread RUDS should be mandated in an effort to curtail the risk to patients who are exposed to health care providers at risk for substance use disorder (SUD). Although there can be no doubt that those with ready access to potent sedative, hypnotic, and analgesic drugs have a significant and dangerous propensity to abuse those drugs, and—along with the general population—have a shared risk of alcohol abuse,2,3 we disagree with Rice et al1 that RUDS is an appropriate response. Instead, we propose an alternative solution for limiting the adverse consequences of drug diversion and abuse by anesthesia providers. Two academic anesthesia departments have reported on their implementation of RUDS programs, in one case, for only anesthesia residents and in the other, all anesthesia providers.4,5 Although the logistics of maintaining these programs accrue considerable effort and personnel cost, neither program was able to demonstrably reduce SUD. One important factor limiting the utility of RUDS among anesthesia providers can be traced to the biostatistical formula for positive predictive value (PPV). It is axiomatic that, when screening a large number of people for a rare event, there will inevitably be false positives even with a screening test with high sensitivity and specificity. As an example, assume a drug screen has 99.9% sensitivity and 99.9% specificity. Assuming a 3 in 1000 prevalence of the target condition (as Warner et al2 reported for the rate of SUD among anesthesia residents), the PPV equation shows as follow: This is to say, because of arithmetic factors alone, a highly functioning RUDS program would carry a 25% false-positive rate. Unfortunately, RUDS among anesthesia providers contains neither a 99.9% sensitivity nor specificity rate, and thus the odds of falsely accusing a health care provider would be >25%. This error rate is consequential for all persons, but especially so for health care professionals who daily depend on their licensed ability to deliver controlled substances to patients. Any positive results on an immunoassay screen of urine, whether truly or falsely reflecting the presence of the target drug in urine, will next move on to confirmatory testing with either gas chromatography/mass spectrometry or liquid chromatography/mass spectrometry that are considered as the gold standards of definitive tests. Unfortunately, as documented by Fitzsimons et al,6 these screening tests are not infallible. Inevitably, there will be false positives when screening broadly for rare events. Why are we perseverating on this point? We do so because a false positive can be ruinous to the career of an innocent anesthesia provider. Those who blithely state that a simple retesting of the split sample, ultimately resulting in a negative screen, will entirely clear the reputational damage of the wrongly accused provider are naïve. Confirmatory retesting takes many days to obtain results, with subsequent clearance from the Medical Review Officer for return to work. When an anesthesia provider suddenly goes missing from the workplace for days, with inquiries to supervisors from concerned colleagues being met with stony silence, the assumption among many will be that their colleague was diverting workplace drugs. The damage to their reputation is done, without a word being spoken. Further, RUDS is defeatable by highly motivated, highly intelligent people who have ample access to background information.7 For example, a Web search on the phrase “how to beat a drug test” will return 3,670,000 responses (Google search November 18, 2016). Many of the suggested methods do not work, but some have been proven to be effective in creating a false-negative test using dilution, adulteration, or substitution. Although specimen-collection protocols attempt to prevent test subversion, only highly invasive protocols, such as those used by the U.S. military and overseers of elite-level athletes, can hope for success. If the person being tested is permitted any privacy in delivering a urine sample, the opportunity exists to provide a tampered or substituted specimen. RUDS are commonplace in the U.S. military. The conduct of obtaining and securing urine samples is well established and consistent across all military branches. Each military unit typically possesses several individuals with urinalysis training who ensure proper collection and security of the sample during transport and analysis. The reporting process is also highly standardized and secure. Urine samples testing positive for illicit substances or medications for which the military member does not possess an active prescription initiates an investigation likely to result in discharge from the military. In a typical military RUDS event, individuals are selected randomly from a unit roster and then isolated from the unit. All personnel at all ranks are subjected equally to testing. These individuals do not have free access to restroom facilities that will later be used for securely obtaining urine samples. Security personnel oversee the urinalysis waiting area and latrines. Men providing urine are allowed to wear only T-shirts on their torsos. Male urine is collected at a urinal with the donor male genitalia in full view of the trained urinalysis observer, who stands directly alongside the donor and observes the passage of urine from the penis into the collection container. Women providing urine are allowed only a brassiere and T-shirt on their torsos. Female urine is collected in a bathroom stall with the testee squatting above the toilet with her pants below her knees and the stall door opened. The female genitalia must be in full view of the trained urinalysis observer female who stands in a position for observing urine flow from the urethra to the collection container. In both circumstances, only the urine donor touches the collection container until the sample is verified with name, identification number, and photo identification. The sample is secured in a shipping container with other samples until all samples have been collected. Elite athletes similarly must provide a specimen in such a closely witnessed manner under protocols dictated by the antidoping agencies.8 Any lesser form of witnessing has proven to encourage attempts at urine sample tampering by those unwilling or unable to cease the use of their drug of choice.7 Although Rice et al1 do not specifically address how intrusively they would propose to witness specimen collection, we think it unlikely that such intrusiveness would be tolerated either by anesthesiologists or by the courts. Are we suggesting maintaining the status quo, or that nothing can be done to address the hazards created by the diversion of workplace drugs? Not at all. In the past 20 years, we have seen a dramatic decrease in diversion from the Mayo Clinic operating room environment that we attribute to much more strict control and accounting for injectable anesthetic drugs and supplements with abuse potential. Details of the successful system employed by Mayo Clinic are reported elsewhere.9 In brief, the Mayo Clinic system uses automated dispensing cabinets to handle the inventory. Although this element alone does little to discourage drug diversion by health care personnel, the system also requires return of the unused portion of the drugs in a secure and chain-of-custody manner. These methodologies allow overseers to test for diversion or tampering of the sample. This is a logistically cumbersome and personnel-intensive (and therefore expensive) solution, but it has proven for years to be effective in curtailing diversion. By creating a system-wide drug diversion detection system at Mayo Clinic, it has become abundantly clear that much drug diversion occurs outside of the operating room environment, and by individuals other than direct anesthesia providers. Drug diversions have been shown to be a significant risk not only to the diverters but also to their patients.10 As such, we question why Rice et al1 would limit their drug diversion and abuse surveillance approach only to anesthesia providers. Restated, if Rice et al1 and their supporters continue to argue for RUDS, should not that testing be applied to all who have access to dispensed and discarded drugs, using the same high-standards of screening employed in the military? And who would be compelled to bear the significant expense of instituting and maintaining a RUDS program, especially one that is required to be system wide? Sadly, there is at least one example of a patient who came to harm under the care of an anesthesiologist who might have been impaired at the time from diverted opioid medications.11 Although it may seem counterintuitive, there are, however, no data published within the indexed literature (or other authoritative sources) to support the contention that SUD presents an acute, population-wide danger to patients or that RUDS would mitigate what risk there is. Although no one would willingly undergo anesthetic care rendered by an impaired anesthesiologist, the American Society of Anesthesiologists Closed Claim Project makes no mention of SUD being a contributing factor in patient harms.12 Until there is adequate empirical evidence to direct our actions otherwise, we strongly believe that the reputational risk of a false-positive assessment for diverted or abused drugs, coupled with the relative ease of tampering in unwitnessed RUDS, recommends against the imposition of RUDS on anesthesia providers. Instead, we propose a proven counter solution to the problem that Rice et al1 are trying to address. It seems as though these authors’ main contention is that we must be seen by society to be doing something to counter the hazards posed by anesthesia providers with SUD. We heartily agree, but if an expensive and logistically cumbersome solution to this problem is to be imposed, we would like it to be one with proven effectiveness. In any event, any RUDS protocol that is not intrusively witnessed and held to the highest standards of security will incur great financial cost to the employer and loss of employee trust and morale. Such activities, we argue, are more gratuitously symbolic than efficacious. Metaphorically, we believe that they represent little more than micturating into the wind. DISCLOSURES Name: Keith H. Berge, MD. Contribution: This author composed the first and subsequent drafts, and this author is responsible for the tone and content of the editorial. Name: Brian P. McGlinch, MD. Contribution: This author provided content and insights related to drug testing in the U.S. military, and provided editorial input. Berge contributed approximately 75% of the effort, and McGlinch contributed the other 25%. This manuscript was handled by: Richard C. Prielipp, MD.