Leading lights behind ACLP’s new addiction and toxicology SIG presented a general session on the subject at CLP 2018. Extracts are below: the full recorded session can be found in the Academy’s Live Learning Center
Results from lab tox tests—with their false positives and false negatives caused by physiological and environmental factors, and their inability to detect the latest designer drugs—inform a treatment plan and contribute to data for the patient encounter.
But, test results remain no substitute for an effective relationship between the C-L psychiatrist and the patient, says JJ Rasimas, MD, PhD, FACLP.
Sometimes, however, clinicians risk using lab data to justify what he describes as a wrong-headed “Gotcha Continuum”—a process through which patients are “found out.”
For example, some patients providing a urine sample substitute their sample with clean urine from someone else (devices to keep urine warm for this specific purpose are on sale on the Internet). In practice, “we should be spending more time on how patients give us their urine,” says Dr. Rasimas, and we should question lab feedback to check, for example, whether results are consistent with human urine.
But, drug addiction for patients comes with “a terrible burden of difficult feelings”—shame, loneliness, money worries… A patient’s mindset could be: “I’m going to lose my wife if I can’t pay the rent. I’m paying the rent by taking the buprenorphine you gave me and selling it to people to get some money. I just put a little of it into my urine so that you would know I’m trying.”
So, the relationship C-L psychiatrists have with their patients, based on “common ground and real regard,” is an over-arching, powerful contributor to the treatment plan. “We must make sure that the knowledge we garner [from drug tests] is an add-on to the first principle of being a doctor who cares,” says Dr. Rasimas.
Practical, ethical and legal considerations also come into play, such as:
Tox tests can be invasive. “Many people with drug use histories have trauma histories, predating and then running concurrent with addiction,” says Dr. Rasimas. “There is an interplay between how invasive we are and how reliable the test is. We need to oversee more to be sure that we are getting good urine, but if we invade more with patients who have an addiction history, overlaid by a trauma history, it can be tricky to be empathetic and caring. We need to be smart about this, but we need to be thoughtful too.”
Lab tests are often used to verify sobriety, confirm adherence to a controlled substance, investigate mental status changes… The results often have weighty consequences, including removal from an organ transplantation list, stigma, legal or occupational ramifications, or damage to the patient-provider alliance. “Constructively integrating the data and our impressions into clinical care requires a thoughtful approach.”
“We must make sure that the knowledge we garner [from drug tests] is an add-on to the first principle of being a doctor who cares.”
—Dr. Rasimas
Tox tests become more useful when the patient has control over part of the test, says Dr. Rasimas, and consults become more effective when C-L psychiatrists are transparent with their patient, including over the reliability of some tox tests.
“I think the right way to handle this is to acknowledge the fact that, since Dr. Google does exist and our patients do look thing up, we should be straight about the fact that lab tests are limited,” he says. “Look them dead in the eye and say: ‘It is true that this lab test does not tell me you have addiction; I do have concerns, however, because the story of your life tells me you have an addictive problem. The drug test may, or may not, tell me that you may, or may not, be exposed to an addictive compound that will show false positivity, or not, in the next three days … but I care about you and I want to know about you.’
“And just admit it, out loud, because that kind of confession is a starting-point to more of a real conversation.”
Transplant psychiatrist Filza Hussain, MD, focuses in the general session recording on nicotine and metabolites. Among factors, she talks about an exponential increase in vaping and e-cigarette sales between 2010 and 2016, and how cigarette manufacturers had gained 87.8% market share in the e-cigarette market by 2016. “That’s frightening,” she says.
Dr. Hussain compares approaches to e-cigarettes in the US and in the UK where the National Health Service (NHS) advocates vaping as an alternative to real cigarettes, despite a 2018 NHS study showing e-cigarettes may make lungs vulnerable to infection. “The jury’s out on that,” she says.
The general session, Addiction Toxicology in C-L Psychiatry: A Broad Topic with Deep Implications, is available in the Academy’s Live Learning Center
Also see: “New SIG Aims to Mobilize Expertise in Addictions and Toxicology”, this issue.