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We need to talk
about drug testing,
says Nick Goldstein
D
rug screening toxicology is the technical analysis of biological
specimens to detect the presence of specific parent drugs or their
metabolites. That’s the dictionary definition and although hair, blood
and saliva are also occasionally used for testing, the gold standard and
most common biological specimen used for testing is urine, leading to
the less rarefied label of ‘piss test’ – or ‘whizz quiz’ for our American associates.
Urinalysis has been around for a while. The ancient Chinese used it as a primary
diagnostic tool and in ancient Greece, Hippocrates was incorporating Sumerian and
Babylonian ideas of urine analysis from 4000BC into his theory that urine was a
filtrate of the humours. (He was, amazingly, right about urine – if a little off with
the humours.) It took Galen in 6AD to link urine to the blood and create the modern
scientific concept of urinalysis.
So, urinalysis has been around a long time and like everything in life, its
philosophy and purpose has changed and morphed to reflect societal development
and changing needs. Cheaper testing kits, an intolerance of drug use and
misunderstanding of intoxication have resulted in what was once an essential,
medical diagnostic tool morphing into a monster tool of social control with
tentacles in every area of society, ranging from pre-employment and employee drug
testing, to concerned parents drug testing their children, to mandatory probation
and children’s social services drug testing. A couple of minutes googling ‘drug tests’
illustrates the scope of urinalysis in the 21st century.
As ever, substance misuse treatment is a mirror of wider society and the same
increase and misuse of urinalysis can be found in the treatment system. It first
appeared for service users shortly after the 1971 Misuse of Drugs Act and when I
first arrived in treatment 15 years later, its role hadn’t changed much. It was, then,
mainly used at the start of treatment, during titration, when the user and their
state of addiction were unclear. After the user had adapted to OST and had formed
a relationship with their treatment service, urinalysis was rarely used and when it
was employed it was for a clearly defined, specific purpose.
However, in the last decade the use of urinalysis has exploded in substance
misuse treatment services, with testing becoming the norm at every appointment
and by request. A sizeable amount of money is now going towards it, which could
be better spent elsewhere.
C
all me cynical, but I believe the two major drivers in the increased use
of testing are cost and changing philosophy. The cuts of the last decade
have significantly impacted on the recruitment and training of key
staff, lowering the quality of frontline drug workers. Urinalysis testing
has become a cheap replacement for less invasive methods of
assessment and a fig leaf for the lack of clinical judgement.
It should be pointed out to policy makers and service commissioners that the
use of urinalysis is a false economy, because it comes with a hidden cost – the
quality of relationship between service user and service. It’s hard to view this
relationship as therapeutic when you’re constantly being tested by rote and every
test is the equivalent of the service saying, ‘I hear what you’re telling me, BUT I
don’t believe a word you say. So, I’m going to pay more attention to your bodily
fluids than the words from your mouth, because my clinical skills are so poor and I
have no other way of ascertaining what might be going on with you.’ Getting tested
for no good reason is demeaning at best and dehumanising at worst. It most
certainly isn’t therapeutic.
It would be remiss to suggest there isn’t a role for urinalysis in treatment in wider
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society. In treatment there are plenty of people who actually like the extra discipline
that comes with frequent testing – and who wants to get on an aeroplane with a
stoned pilot? The problem is drug testing has spread far beyond its original, suitable
role and become a cheap tool of behaviour modification and control.
Which brings us to the change in core philosophy that filtered in with the
coalition government and their ‘Roadmap to Recovery’ agenda. Back in the day,
treatment was seen as successful if it improved the life and health of the service
user. Non-compliance wasn’t a hanging offence and would be met with a discussion
of what could be done to help the service user. Remember that? Well, things are
very different now, even if compliance is slowly replacing abstinence as the sole
purpose of treatment. Substance misusers are now just one of several vulnerable
communities who’ve seen their services turned into hostile environments for
political ends.
This hostile environment has reduced the number of users accessing treatment
and reduced time spent in treatment, which might look good on paper, but is far
from a ‘positive outcome’ for service users in the real world.
The change in philosophy is summed up by an anecdote a friend told me. After
her service was recommissioned to a recovery-orientated service she was tested
before her first appointment and it came back positive. This failure led to her key
worker observing that maybe she should think about leaving treatment because it
wasn’t working for her. Obviously, this motivated her to make sure her next test
came back negative – whereupon the key worker suggested that she should think
about leaving treatment because the treatment was working! Amazingly she’s still
hanging on in treatment – no thanks to her treatment provider.
S
o here we are; vulnerable users’
treatment services have been
morphed into a hostile environment
for political ends and blanket
urinalysis drug testing has been one
of the major instruments of that change.
To add insult to injury, the reliability of drug
tests has long been questioned and there’s
plenty of anecdotal evidence of both false
positives and negatives, but it’s hard to access
meaningful statistic data on reliability.
Whatever the reason, an area of silence has
been created around the subject; it should be a
national scandal that major decisions affecting
people’s lives are taken on the back of such
questionable results.
We need to talk about this now because, as
ever, more change is coming and if we don’t
have a conversation about drug testing in
treatment and wider society the issue will only
spread like a fetid puddle of urine.
As it is, substance misuse services are
becoming cheap, low quality, one size fits all. If
you don’t fit you’re gone, and if we leave the EU
and more importantly its Social Chapter, one of
our main lines of protection relating to both
drug testing and wider substance misuse treatment will end and really radical
change could become possible. As it is, we live in a world where highly questionable
drug testing decides our liberty, employment and treatment among other
fundamental aspects of our lives, and the situation will only deteriorate without
some sort of intervention.
Coda – within a few days of writing the above I noticed an article that suggested
the future of drug testing will be intelligent fingerprinting which analyses the
chemicals secreted in a subject’s fingerprints – a new ‘non-invasive and dignified’
means of testing, according to the manufacturer. While it’s good to see that even
those involved in drug testing realise how soul destroying urinalysis actually is, it’s
sad to see the technology remorselessly advancing without any debate on why we
drug test and what we hope to achieve with it.
Nick Goldstein is a service user
‘Back in the day,
treatment was
seen as
successful if it
improved the
life and health of
the service user.
Non-compliance
wasn’t a
hanging offence’
April 2019 | drinkanddrugsnews | 13