Strengths
of mandatory drug testing and conditional treatment
Effects of treatment on employability
Generally,
substance abuse groups that receive treatment have higher rates of employment
after treatment than before treatment (Center for Substance Abuse Treatment,
1997). Therefore, requiring welfare recipients to obtain treatment may
lead to subsequent improved rates of employment among this group.
Mandatory or conditional treatment
There
is evidence in the literature that conditional treatment can produce positive
outcomes in terms of substance abuse. For example, employees who are on
the verge of losing their jobs due to performance problems related to
substance abuse have shown improvements when offered treatment (Macdonald
et al., 1997). Similarly, court diversion programs where DWI offenders
have been offered treatment have produced better results than punishment
(Wells-Parker et al., 1995).
Treatment enrollment, treatment compliance and treatment completion
Mandating
clients to attend treatment as a condition of receiving social assistance
would likely increase the number of drug and alcohol users who enroll
in treatment programs. Rates of treatment compliance and completion also
could be expected to increase for those who enroll under these circumstances.
Limitations
of mandatory testing and conditional treatment
Limitations of drug tests
Urinalysis
can only be used to determine whether drug metabolites are present in
the urine. The tests can not measure impairment (i.e., deteriorated performance),
habituation, dependence or addiction.
Drug
tests are generally conducted to detect five classes of drug metabolites:
cannabis, cocaine, opiates, benzodiazepines and amphetamines. Since different
drugs are eliminated from the body at different rates, drug tests can
detect use of some drugs more readily than others. For example, cannabis
use can be detected if it was used as long ago as three weeks before the
test, whereas cocaine use can only be detected if use occurred within
a few days before the test. Other substances, such as sedatives, alcohol,
hallucinogens and solvents, which have the potential to affect employability,
are not routinely included in standard drug tests or are difficult to
detect. Drug tests do not address the full range of drugs that could interfere
with employability, and do not detect the drug most likely to cause work
problems, namely alcohol.
The need for clinical assessments
Since
the tests can not be used to distinguish dependence from occasional use,
comprehensive clinical assessments are still needed to diagnose the presence
of a substance use disorder. In fact, 70% of people who use drugs are
gainfully employed. A comprehensive assessment should include a thorough
substance use history, a full psychosocial history and a medical examination
(and associated tests) to determine if there are signs of illness or compromised
functioning that might be related to substance use. Collateral information
from key informants (family, friends) is useful for verifying client self-reports.
Confidentiality and the absence of adverse consequences also improve the
accuracy of self-reports (Donovan & Marlatt, 1988).
Variations in the effects of different drugs
The
pharmacological properties, addictive and long term harmful effects vary
considerably among the drug classes that are tested. For example, cannabis
is not highly addictive and use will usually not affect employability.
In contrast, cocaine is more addictive and long term use could interfere
with one's employability, although most people who use cocaine do not
become dependent. Also, most people who use drugs do not use them at work
(Newcomb, 1994).
Negative consequences of conditional welfare benefits
Providing
welfare on the condition that clients are drug free or participate in
a treatment program could result in negative societal consequences, such
as increased crime and social problems. A study in the United States examined
the impact of eliminating disability benefits (Goldstein et al., 2000).
While some people went back to work, others increased their criminal activities.
Those who suffered the most had pre-existing physical and mental disabilities.
This latter group became a larger burden on the health system as many
of them became sicker. Also, clients who have no desire to change their
behavior may be disruptive to the treatment process and undermine the
efficacy of treatment for other individuals. This is particularly the
case where therapy is offered on a milieu or group basis, which could
have a negative effect on treatment participation and completion of non-mandated
clients in these programs.
About
70 per cent of substance users have at least one relapse in the first
year after completing treatment (Annis et al., 1998). A policy that demands
abstinence from drugs as a condition of receiving welfare likely will
not be effective since relapse is so common. Rather, such a policy may
result in negative societal consequences as described above.
Disruption to the client and case manager relationship
Case
managers for welfare recipients can be instrumental in assisting clients
to obtain employment. Case managers are generally most effective when
they build a trusting relationship with the client. Drug testing has the
potential to undermine this relationship by creating an adversarial process,
which could be counterproductive to the joint goal of obtaining employment.
Furthermore, many factors such as physical and mental health problems,
lack of job skills, perceived discrimination, and lack of transportation
are major barriers for employment (Danzinger et al., 1999). A disproportionate
emphasis on drug use as a factor for not obtaining employment can also
be counterproductive for employability.
Human rights issues
Drug
testing and mandatory treatment of welfare recipients could be challenged
on legal grounds. Under the Ontario Human Rights code, alcohol and drug
dependence is considered a handicap. Failure to provide welfare benefits
on the basis of substance abuse may constitute discrimination. Also, a
legal challenge could be brought under the Charter of Rights and Freedoms
against both mandatory drug testing and mandatory treatment.
Cost issues
Various
financial costs will be incurred in order to implement the proposed changes.
Increased costs are associated with conducting the drug tests, increased
clinical assessments and increased substance abuse treatment. The total
costs increase as a function of the number of people who test positive.
Any
drug testing regime must include procedural safeguards to ensure accurate
findings. The process must be rigorous and adhere to widely recognized
forensic standards including proper qualifications of the staff, collection
of samples under direct observation, chain of custody, documentation and
regular inspections (Kapur, 1994). As well, positive results should be
reviewed by a Medical Review Officer, who must be able to discuss and
interpret positive test results with the client. All positive test results
must be re-confirmed by more advanced and costly methods, usually gas
chromatography and mass spectrometry. These procedures will cost approximately
$2,000 for each positive test.
As
previously indicated, clinical assessments are still needed for those
who test positive in order to determine whether treatment is required.
These assessments along with a possible need for increased capacity of
treatment for clients with substance abuse problems will produce additional
costs to the health care system.
Conclusion
Drug
testing has limited utility in terms of determining the need for treatment
and increasing employability of welfare recipients. The tests cannot be
used to determine substance abuse and do not address the full range of
drugs that could interfere with employability. Costly clinical assessments
will be required to assess substance dependence problems, and the current
treatment system does not have the capacity to address increased demand
for treatment services. Drug testing also undermines the client-case manager
relationship, which will have a negative impact on the goal of employability.
While there is some evidence that substance abuse treatment can increase
employability for those with alcohol or drug problems, the issue of conditional
treatment has drawbacks, such as potential negative societal consequences,
disruptions to the treatment population and additional financial costs.
Conditional welfare, based on abstinence from drugs has similar drawbacks.
Moreover, the denial of benefits to those with substance abuse problems
may produce increases in crime, health problems, and other societal costs.
Recommendations
-- We do not recommend drug testing of welfare recipients.
-- We do not recommend removal of welfare benefits for people who refuse
treatment or relapse.
-- Individuals who use drugs should have the same access to welfare
benefits as other residents, irrespective of whether they need or receive
treatment. Substance abuse treatment should be available to welfare
recipients and other socially disadvantaged individuals. The need for
treatment should be determined through clinical assessments and a strategy
for treatment should be agreed upon jointly by the client and case manager.
References
Adlaf, E.M., Paglia, A., & Ialomiteanu, A. (1999). Ontario Drug
Monitor 1998: Alcohol, tobacco and illicit drug use, 1997-1998. CAMH
Research Document Series No. 4. Toronto: Centre for Addiction and Mental
Health.
Annis, H.M., Herie, M.A., & Watkin-Merek, L. (1998). Structured
Relapse Prevention: An Outpatient Counselling Approach / Prévention
structurée de la rechute: Modèle d'orientation en consultations
externes. Toronto: Addiction Research Foundation.
Boyle, M.H., Szatmari, P., Offord, D.R., & Merikangus, K. (1990).
Substance use among adolescents and young adults: Prevalence, socio-demographic
correlates, associated problems and familial aggregation, Working Paper
No. 2. Toronto: Ontario Ministry of Health.
Centre on Addiction and Substance Abuse. (1994). Substance Abuse
and Women on Welfare. Columbia University.
Center for Substance Abuse Treatment. (1997). Substance Abuse and Mental
Health Services Administration. "The National Treatment Improvement
Evaluation Study".
Danziger, S., Corcoran, M., Danziger, S., Heflin, C., Kalil, A., Levine,
J., Rosen, D., Seefeldt, K., Siefert, K., & Tolman, R. (1999). Barriers
to the Employment of Welfare Recipients, Poverty Research and Training
Centre, University of Michigan (July).
Donovan, D.M., Marlatt, G.A., editors (1988) Assessment of Addictive
Behaviors. New York: Guilford.
Fraser, A.D. (1998). Urine drug testing for social service agencies
in Nova Scotia, Canada. Journal of Forensic Sciences, 43(1),
194-196.
Goldstein, P., Anderson, T.L., Schyb, I., & Swartz, J. (2000).
Modes of adaption to termination of the SSI/DI Addiction Disability:
Hustlers, good citizens, and lost souls. Advances in Medical Sociology,
7, 215-238.
Grant, B.F., & Dawson, D.A. (1996). Alcohol and drug use, abuse,
and dependence among welfare recipients. American Journal of Public
Health, 86(10), 1450-1454.
Kapur B. (1994). Drug testing methods and interpretations of test results.
In: Macdonald S, Roman P (eds.) Drug testing in the workplace, New York:
Plenum Press.
Kirby, G., Pavetti, L., Kauff, J., & Tapognia, J. (1999). Integrating
alcohol and drug treatment into a work-oriented welfare program: Lessons
from Oregon. Mathematica Policy Research, Inc.
Macdonald, S., Lothian, S., & Wells, S. (1997). Evaluation of an
employee assistance program at a transportation company. Evaluation
and Program Planning, 20(4), 495-505.
Miller, W.R., Rollnick, S., (1991) Motivational Interviewing: Preparing
People to Change Addictive Behavior. New York: Guilford.
Newcomb M. (1994). The prevalence of alcohol and other drug use on
the job: cause for concern or irrational hysteria? Journal of Drug
Issues, 24, 403-416.
Wells-Parker, E., Banger-Drowns, R., McMillen, R., & Williams.
M. (1995). Final results from a meta-analysis of remedial interventions
with drink/drive offenders. Addiction, 90, 907-926.
Fiscal
Considerations With Respect to Mandatory Drug Testing for Welfare Recipients
General Considerations:
This
discussion is written in support of the Centre for Addiction and Mental
Health's Position Paper on Mandatory Drug Testing for Welfare Recipients.
It assumes that the any government which introduced such testing would
rely on urine specimens tested for the presence of psychoactive substances
and that the collection, testing and interpretation of results would be
done in a way which is most likely to withstand a legal challenge to this
process. It does not address other issues, such as human rights violations,
which may also result in legal challenge.
The
widely accepted standards for drug testing, and those which have been
most thoroughly tested in the courts, are those established by the United
States Department of Transport (USDOT) for safety-sensitive employees.
The purpose of the USDOT drug testing is to function as a deterrent to
drug or alcohol use. This is different from the stated goal of the Ontario
government of identifying individuals to be referred to mandatory treatment.
Nevertheless, the USDOT standards for collection, testing and interpretation
will serve as a guide to the following discussion of issues to be considered.
A more complete reference to the USDOT standards can be found in "The
Medical Review Officer's Manual: MROCC's Guide to Drug Testing" (ed.
Swotinsky, R.B. & Smith, D.R., 1999, published by OEM Press, Beverly
Farms, MA for the Medical Review Officer Certification Council).
Collection:
Urine
samples to be tested for the presence of drugs must be collected in a
way that ensures respect for the donor's privacy while taking safeguards
against interference or error in the process. At times this may require
direct observation of the provision of the sample. More usually the donor
will be provided with the opportunity to provide the sample in a private
setting where the possibility of interference with the process is limited.
Such steps as checking the temperature of the urine, turning off the hot
water in the donation location, bluing the water, etc. all limit the possibility
of tampering with the sample or the process. In addition, collection of
the samples on a random frequency with limited donor notice period will
increase the effectiveness of the process. There would be a significant
cost attached to all samples, negative and positive, as a result of the
facility and staff costs of sample collection. However, failure to collect
the samples in the appropriate method will introduce opportunities for
the donor to circumvent the process rendering the meaningless or difficult
to interpret.
Transportation and Handling:
From
the moment of collection and throughout the transportation and handling
of samples as well as the testing and interpretation of results, there
must be no possibility for samples or results from different donors to
be confused. The prevention of such errors is accomplished by establishing
a carefully maintained and documented chain of custody process. The chain
of custody process has been well established by the USDOT standards and
should include such measures as individual packaging of samples in containers
sealed with tamper-proof tape, a complete documentation process and other
measures. There would be costs attached to all samples collected, both
negative and positive, for the materials and staff training required to
maintain a complete chain of custody. Failure to maintain a chain of custody
would likely prevent any action taken on the results of testing from withstanding
a legal challenge.
Laboratory Testing:
Laboratory
testing of samples would be required to be done in a manner that eliminates,
as much as possible, the risk of technical or human error. There are internationally
recognized certification standards by which a laboratory facility can
be chosen to reduce the risk of human error in the process. In terms of
technical error, all laboratory testing procedures have a defined rate
of false-positive and false-negative results when compared to a gold standard
method. To reduce the possibility of results being incorrectly reported
as positive samples reported as positive on a screening test should be
retested using the gold standard method (in this case, gas chromatography-mass
spectroscopy or GC-MS). There would be a certain cost associated with
applying a screening test to all samples, both negative and positive,
and a significant cost with performing confirmatory testing on all samples
which screen positive. The exact cost of the screening tests will be dependent
on the number of different substances being screened. In addition, there
may be laboratory costs for additional tests done to detect the presence
or absence of attempts by the donor to invalidate the process through
adulteration or dilution of the sample.
Interpretation of Results:
Many
circumstances may arise whereby a donor's urine sample will test positive
for a substance which may either represent appropriate use of a substance
for a legitimate medical purpose or represent use of a psychoactive substance
for other reasons. For this reason there is a need for an independent
review of the results by an appropriately trained physician who neither
represents the laboratory, the donor nor the agency requiring the testing.
This person is typically referred to as the Medical Review Officer (MRO)
and there is a widely recognized training and certification process in
place for the MRO. Generally the MRO should receive copies of all results
including documentation of the chain of custody process. The MRO is responsible
for reviewing and approving the process for all negative samples before
the result is released to the agency requiring the testing. For positive
samples, the MRO must contact the donor to verify whether or not the result
is due to a legitimate medical purpose (and there are legally tested standards
for this determination) prior to the release of the result to the agency.
Typically, medically justified results are reported as negative to the
agency by the MRO to protect the donor's privacy around medical conditions.
The interpretation of results by an MRO will result in a cost attached
to all samples to account for the time and expertise of the MRO.
Expert Involvement:
The
involvement of experts from the laboratory or the MRO in legal challenges
to the process or decisions made on the results may result in significant
costs over and above those involved described above.
Summary:
The
institution of mandatory drug testing for welfare recipients would be
a costly endeavor. Beyond the capital and staff training costs of establishing
such a process, there would be significant on-going costs for laboratory
services and results interpretation. Failure to invest in this process
adequately would result in an increased likelihood of inability to act
on the results of the drug testing (either because the results were rendered
invalid or as a result of legal challenge). On the other hand, it is not
difficult to estimate these costs as being substantial. If the costs of
additional technical and expert fees attached only to positive results
are averaged over all samples collected a conservative estimate of coast
would be $40-60 per sample. Again estimating conservatively, if as many
as 2-3% of samples are positive (which would be a higher rate than often
seen in workplace testing) the cost per positive sample would be in excess
of $2000. In considering these cost estimates it is important to bear
in mind that not all individuals who test positive for substance use will
have problematic substance use requiring treatment so the cost per individual
appropriately referred into treatment will be even higher.
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