Why drug testing won’t ensure drug-free workplace

Hospitals should have a comprehensive program

Chances are, one out of every 12 of your hospital’s employees abuses drugs or alcohol. A recent national survey found that 70% of illegal drug users are employed, and that about 7.7% of employees use illicit drugs.1

Even if you screen potential employees before you hire them, you probably don’t have a drug-free workplace. Hospitals need comprehensive policies, procedures, and education programs to identify and respond to substance abuse among employees, says Kathleen Golden McAndrew, MSN, ARNP, COHN-S, CCM, department director and nurse practitioner in the section of occupational medicine at the Dartmouth Hitchcock Medical Center in Lebanon, NH.

The bottom line, says McAndrew, is fitness for duty. While a drug test may be helpful, it is just one component of the work fitness evaluation of employees, she stresses.

"I think so many people rely on drug testing, and it’s got its limitations," McAndrew says. "Instead of sending an employee to a health care provider for evaluation, they jump into drug screening. First, they need to sit down and talk to him or her and ask what’s going on."

A work fitness evaluation looks for medical problems, including substance abuse, that could be causing a problem with performance.

"The majority of work fitness evaluations I do are not substance abuse problems, but I do go through the process" of looking for signs and symptoms of drug use, says McAndrew. Some times, no medical problem or substance abuse is found, and the matter becomes purely a job performance issue.

Health care workers may have a higher risk of abusing prescription drugs, if only because of their access to them. Some employees may try to counteract the effects of job stress and the physical demands of working night shifts with prescription drugs.

A survey of 4,438 registered nurses found that 32% had used marijuana, cocaine, or prescription-type drugs or engaged in binge drinking or smoked at least half a pack of cigarettes per day during the last year.2 (The study asked about any use, not just ongoing use or addiction.) Nurses in emergency care, critical care, oncology, and psychiatry had the highest rates of substance use. (For more information on the study, see Hospital Employee Health, July 1998, pp. 86-88.)

At Baystate Health System, a three-hospital system in Springfield, MA, employees receive monthly safety training, including an annual module on substance abuse. Employees who disclose a substance abuse problem receive treatment and retain their jobs. Even employees whose substance abuse problem was detected after suspicions by a supervisor or co-worker could receive rehabilitation, along with a two-year period of random drug testing.

"Policies should be oriented toward rehabilitation rather than being punitive," says James Garb, MD, Baystate director of occupational health and safety. He adds, "You have to have a threshold that you’ve reached and can’t just keep enabling."

Policies are much stricter if the employee negatively affected patient care, perhaps by diverting drugs that were meant for patients. State laws and licensing board rules also vary in what must be reported and what punitive action is taken.

An employee’s substance abuse problem is confidential, even from a supervisor who reported suspicions. McAndrew notes that she simply discusses the person’s fitness for work.

"We want people here who can safely perform their job duties," she says. "We consider this a medical reason. When they come back, they come back under a contractual arrangement that the supervisor knows about. We don’t have to tell them the details."

Employee health policies need to address spe cifically the roles of hospital administration, supervisors, employees, occupational health and safety employees, and the employee assistance program. Stipulations about the circumstances in which employees are allowed to return to work should be clearly stated, McAndrew advises.

McAndrew teaches supervisors about signs in behavior, appearance, and work performance that could indicate drug abuse.3 But it is still a challenge to determine whether unusual behavior is linked to drug use.

Garb recalls one four-month period in which three employees were referred for possible substance abuse problems, but all three had serious medical conditions instead. For instance, a physician was losing weight, had hand tremors, and was making errors. Tests showed he had an overactive thyroid.

In another case, a young nurse was coming in late, looking disheveled, and making mistakes. When Garb took her history, he learned that she was falling out of bed at night and was unable to get back in. "That’s not the story of a drug user," he says. "There was clearly something else going on."

It turned out she had a brain tumor, as did a secretary who had previously been treated for breast cancer.

"One potential hazard for employee health practitioners is forgetting to look for some of these other medical problems," says Garb. "You don’t want to forget to consider the more unusual types of problems."

A work fitness impairment evaluation should take into account the clinical signs, symptoms, and behaviors related to the seven categories of psychoactive drugs: narcotic analgesics, central nervous system (CNS) stimulants, CNS depressants, hallucinogens, phencyclidine, cannabis, and inhalants.

An eye examination can be an important part of the physical evaluation, notes McAndrew. For example, certain drugs may cause nystagmus, an involuntary jerking of the eyes, or changes in the eyes’ response to light.

After a careful consideration of the supervisor’s concerns, the patient’s history, and the physical evaluation, McAndrew may move on to drug testing. "It’s a toxicological confirmation of what your findings are," she says.

Employees may have a longtime substance abuse problem before the symptoms become obvious. Co-workers also may feel uncomfortable reporting someone, particularly if they don’t feel patient care has been compromised. But a confrontation and subsequent treatment may help someone turn his or her life around.

"People can go on for years and put up a pretty good front," says Garb. "Usually it’s one of two things that forces people into treatment: a crisis at home or a crisis at work.

"There are some stories of people who have gone into treatment and done quite well," he says. "You don’t win them all, but there are some really nice saves."

(Editor’s note: More information on creating drug-free workplace policies and programs is available on-line from the Substance Abuse and Mental Health Services Administration at www.health.org/workpl.htm.)


1. Substance Abuse and Mental Health Services Admi nistration. Worker Drug Use and Workplace Policies and Programs: Results from the National Household Survey on Drug Abuse. Washington, DC, 1999.

2. Trinkoff AM, Storr CL. Substance abuse among nurses: Differences between specialties. Am J Public Health 1998; 88:581-585.

3. McAndrew KG, McAndrew SJ. Workplace substance abuse impairment. AAOHN Journal 2000; 48:32-45.