Do random tests bring a 'drug-free workplace'?

Hospitals differ on approach to testing

Truck drivers do it. So do airline pilots and nuclear power plant workers. Should health care workers also be subject to random drug tests?

That's a question that continues to spark controversy. While pre-placement and for-cause drug testing are commonplace in hospitals, employee health professionals have widely different views on random drug testing.

"Many health care professionals are making life-and-death decisions that are just as critical as [those of] air traffic controllers," says Karl Auerbach, MD, MS, MBA, staff physician with the occupational and environmental medicine program at Strong Memorial Hospital in Rochester, NY, and assistant professor at the University of Rochester School of Medicine and Dentistry.

"I would not want my physician or my nurse being impaired by drugs," he says.

Yet some employee health professionals question the value of random drug testing compared to a for-cause program that targets employees who have performance problems combined with a liberal employee assistance program that offers treatment and counseling.

"Drug testing has been around a long time. I think we still don't have a clear vision on the return on that investment," says Mary Yarbrough, MD, MPH, director of occupational health and wellness at Vanderbilt University in Nashville, TN.

Drug screens target high-risk units

Taxi drivers and bus drivers are accustomed to random drug testing. Federal rules require employers with federal contracts to randomly test 50% of their "safety-sensitive" employees for five commonly abused drugs — a high rate intended to act as a deterrent.

Hospitals that use random drug testing typically test a much lower percentage, although they use a broader drug testing panel to include common hospital drugs.

After catching several employees who had diverted hospital narcotics for personal use, Marshfield (WI) Clinic began random drug testing in departments that were deemed to be higher risk, including pharmacy, gastrointestinal surgery, and ambulatory surgery. The testing panels typically include about 10-12 drugs. They vary according to what is used in the unit but often include fentanyl, midazolam, cocaine, amphetamines, and barbiturates. Marshfield Clinic tests about 10% of those employees quarterly.

The testing results are sent to an outside medical review officer (MRO). If a medical substance is detected, the MRO seeks verification that the employee has a valid prescription. Employees who are found stealing drugs from the hospital are handled in a disciplinary manner, but other employees who have positive drug screens are offered treatment opportunities.

Marshfield Clinic now is considering expanding the drug testing program to all employees. "I've worked in the steel industry, the lumber industry, and now the health care industry," says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety. "I don't see a difference. I see a world in which everybody is testing. With the federal Drug-Free Workplace [Act], there are few employers who have federal contracts who are not testing. You have to wonder – the places that are not testing, are they magnets for people who can't get a job elsewhere?"

Strong Memorial Hospital in Rochester does not use random drug-testing. But Auerbach, who is an MRO and moderates an MRO listserv, says that random testing can be effective as a deterrent. It should be used with other programs to detect performance problems that could be drug- or alcohol-related and programs to enable employees to come forward and receive treatment and support.

"You do [random testing] in a way that respects the dignity of the individual being tested, most of whom are not going to be drug users," says Auerbach. "You give everyone an equal opportunity to be tested."

Random testing is just one part of a broader program that includes treatment, he says. "I fully agree with the need for treating drug use in a medical way, in a compassionate way, and offering voluntary routes to take care of the issue," Auerbach says. "That is in no way mutually exclusive to the fact that many people don't come forward. I think it's very important that you have both [elements]."

Dose tracking catches diverters

At Vanderbilt University, Mary Yarbrough, MD, MPH, director of occupational health and wellness, sees a number of conditions that could affect employee performance, from the declining vision of older workers with presbyopia to depression. She wonders how much attention should be focused on random drug-testing in an atmosphere of limited resources.

"I think the way you identify drug users is by watching their behavior," she says. "If we have a limited resource, why not put that money into supporting supervisors in their role [of monitoring performance]."

Yarbrough also favors treating drug abuse as a medical problem and encouraging physicians, nurses, and others to come forward for counseling and treatment. "If you voluntarily come in and seek help, we will be an advocate for you," she says. "If you go to treatment and get help, we will treat this, as long as there's not been any indication that there's been a problem in the workplace."

Bill Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN, also questions the use of resources for random drug-testing. "It fosters an environment of distrust and that's not what we want here at Mayo Clinic," he says. "I'm sure that not what most people what."

Tampa (FL) General Hospital uses the AccuDose-Rx medication delivery system (www.mckesson.com) to monitor narcotic use. For example, the tracking database can produce monthly reports indicating how many doses of meperidine 50 mg for injection are given by each nurse compared to other nurses on their unit or in the entire hospital and can track the dosage by the date and time it was removed, explains JoAnn Shea, MSN, ARNP, director of employee health and wellness. The Employee Health Director and the pharmacy nurse liaison review the AccuDose reports via a computer database monthly and identify and investigate discrepancies.

In one case, a nurse in the recovery room was drawing twice as much morphine as other staff — although his charts didn't show a difference in patient conditions. In another case, an emergency department nurse was taking 100 merpidine a month while co-workers were taking two or three. Those employees were placed in treatment for substance abuse.

Shea estimates that it would cost $20,000 to $30,000 a year to conduct random testing. "Is it really worth it? I'd rather spend that money on promoting health for employees, and spending time identifying the diverters," she says.