| | Drug testing of adolescents in general medical clinics, in school and at home: physician attitudes and practicesReceived 21 June 2005; accepted 9 November 2005. Abstract PurposeTo determine (1) whether physicians agree with recommendations for home and school drug screening, (2) under what circumstances physicians recommend urine drug tests for adolescents, and (3) how physicians manage adolescent patients with positive results. Few clinical practice guidelines have been published on urine drug testing of adolescents, and it is not known when physicians recommend this procedure or how they manage positive results. MethodsMulti-modal survey of a nationally representative sample of physicians conducted April–July 2004. We computed simple frequencies and used backwards selection logistical regression to determine if there were differences in agreement or practices among physicians from different specialties (pediatrics, family medicine, adolescent medicine) or by demographic factors (physician age, gender, practice type or location). ResultsA total of 359 physicians (43% after eliminating ineligibles) completed the survey. Thirty-eight percent would recommend a drug test if were required to return to school, 41% if a parent was concerned, and 46% based on history (without a parent’s concern). Forty-eight percent of physicians would share a positive drug test result with parents. A large majority (83%) disagreed with high school drug testing programs. ConclusionsThere is little consensus among physicians regarding the indications for drug testing in the general medical clinic. However, most disagree with school drug testing programs. There is little consistency among physicians in how to proceed when a urine drug test is positive. Professional organizations should consider publishing clinical practice guidelines in order to assist physicians in using this procedure effectively.
Adolescent drug and alcohol use is a major public health concern in the United States and drug testing of adolescents is an increasingly popular solution. Drugs can be detected in blood, hair, breath, sweat and saliva; however, urine is most often used for drug testing because it is easily obtained and concentrations of drugs are relatively high [1]. Urine drug tests have a number of potential purposes in an adolescent population, including screening of general populations or assessment to confirm drug use when signs of a drug disorder (such as decrease in grades or possession of drug paraphernalia) are present.
High school drug screening programs using urine drug tests have become increasingly popular over the past few years. In the Pottawatomie versus Earls decision, the Supreme Court ruled in 2002 that schools may require drug testing programs for students that participate in extracurricular activities. Following this ruling, the Office of National Drug Control Policy (ONDCP) recommended that high schools screen all students with urine drug tests [2]. Drug testing in some situations is viewed favorably by many parents [3], and parents can now purchase drug-testing kits over the Internet. Several web sites recommend that parents screen their children repeatedly at home to prevent drug use [4]. Despite the increased interest and awareness in drug testing, physicians have had little input in determining how urine drug tests are best used. Yet increased drug testing of adolescents in the community may have profound implications for primary care clinicians. Physicians are likely to receive more requests to order urine drug tests from their offices and more referrals of teens who have had positive drug screens at school or at home. It is not clear how physicians view the use of drug testing for adolescents, under what circumstances they deem it appropriate, and whether they have the resources to assess, treat, or refer patients with positive results. Neither the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), nor the Society for Adolescent Medicine (SAM) have yet published policy guidelines regarding school drug testing or home drug testing.
Despite recommendations from the ONDCP and home drug testing web sites, some medical experts do not recommend urine drug testing as a screening procedure, because screening large populations may be expensive, intrusive and low yield [5]. However, drug-using teens may present for medical care with nonspecific signs, such as fatigue, mood changes, or school failure [6], and urine drug testing may be a useful assessment tool when parents notice these symptoms yet the teen denies drug use. In deciding whether to recommend a urine drug test, physicians must consider the history, the likelihood of drug use, and the ability of the test to confirm particular drugs of abuse. For example, some clinicians may recommend a drug test whenever a parent is suspicious that a teen is using drugs, whereas others may obtain more history and recommend testing only in some cases. Still others may believe that urine drug testing violates the autonomy of an adolescent and never recommend this procedure.
Even if a physician believes that a urine drug test would help to clarify a teen’s diagnosis, recommending a drug test against an adolescent’s will may be detrimental to the physician-patient relationship [7]. The AAP has relevant policy guidelines that state competent adolescents should be given the right of informed assent; parental consent alone is not sufficient for a physician to order a drug test [8]. Similarly, the California Academy of Family Physicians manual entitled Urine Drug Testing in Primary Care states that, “urine drug testing in clinical practice should be a consensual diagnostic test, which is done with the full explanation to and for the benefit of the patient” [9]. Parents, however, do not necessarily agree. In a recent study, a majority of parents (82%) accompanying their teenagers to primary care visits would want a physician to order a urine drug test without the teen’s consent [3]. The discordance between professional recommendations and parental expectations complicates clinical decision-making.
When a physician does get a report of a positive drug test, s/he must then decide how to proceed. For example, if ordered through the office, s/he must decide whether they will report positive results to parents. In all cases, the physician must decide what other assessments or treatments are needed. A single positive drug test is not sufficient to make the diagnosis of a substance use disorder [5]; subsequent assessment is required to determine the appropriate level of intervention.
The growing demand for urine drug testing in response to concern about adolescent substance use necessitates that clinicians understand when and how to use drug testing effectively, ethically, and how to respond to positive results appropriately. Little is known regarding physicians’ urine drug testing practices with adolescent patients, when they recommend this procedure, or whether they agree with published recommendations. The objectives of this study were to determine: 1) whether physicians agree with recommendations for home and school screening programs, and whether they agree with AAP guidelines that advise against drug testing an adolescent against his/her will; 2) whether physicians recommend a urine drug test when requested by a parent, a school, or when a child presents with nonspecific signs associated with drug use; and 3) how physicians proceed when an adolescent has a positive urine drug test in the office, at school, or at home.
Methods  The study was a survey conducted in 2004 of a representative sample of physicians who provide primary care to adolescent patients. Questionnaire development, survey techniques, and data management have been described in a previous report [10]. Briefly, we developed a survey tool after conducting seven semi-structured telephone interviews with practicing physicians and analyzing themes using standard qualitative analysis techniques. The final questionnaire was comprised of 41 forced-choice items designed to assess 1) physicians’ level of agreement with school drug testing recommendations, (i.e., “All teenaged students should be drug tested in schools”)—three questions rated on a five-point agreement scale (strongly agree, agree, neutral, disagree, strongly disagree); 2) how often physicians recommend home drug testing—one question rated on a four-point scale (never, in some cases, in most cases, in all cases); 3) physicians’ level of agreement with the use of drug testing in various office situations (i.e., “I would recommend a teen have a drug test if a parent felt strongly that the child was using drugs and denying it”)—six questions rated on a five-point agreement scale as above; 4) physicians’ usual follow-up practices with drug test results, (i.e., “If a teenager had a positive drug screen, how often would you share the test results with parents?”)—five questions rated on a four-point scale (never, in some cases, in most cases, in all cases); and 5) physicians’ awareness of published drug testing guidelines (i.e., “Does your professional society have published guidelines regarding adolescent drug testing?”)—two questions. We surveyed a nationally representative sample of 1085 physicians drawn from the membership roles of the American Academy of Pediatrics (AAP, 408), the Society for Adolescent Medicine (SAM, 300) and the American Academy of Family Physicians (AAFP, 377) using the Tailored Design Method [11]. Physicians who saw an average of 10 or more adolescents (aged 12–18 years) weekly for primary or urgent care and had valid contact information in their professional society database were eligible. Each selected physician received an introductory cover letter explaining the objectives of the research along with a $2 bill incentive. We used a multimedia strategy, contacting physicians via e-mail, fax or U.S. mail, according to available contact information. Physicians with available e-mail addresses (361) or fax numbers (293) received five contacts; those with neither received three contacts. All selected participants received a minimum of two copies of the survey via U.S. mail. The protocol was reviewed and approved by the Children’s Hospital Boston Committee on Clinical Investigations (IRB). A total of 359 physicians (AAP 122, SAM 126, AAFP 103 and 8 who did not identify their affiliation) completed the survey, and 168 physicians were ineligible, for a calculated response rate of 43% [12]. Physicians who did not identify affiliation with a professional society were included for group analysis only. The response rate was similar for all three professional societies. Data analysis We collapsed response categories for our primary variables of interest for ease of analysis and reporting of results. For the variables addressing agreement, we combined those who selected “strongly agree” with “agree” to indicate agreement, and for variables addressing practice parameters we combined “in all cases” and “in most cases” to indicate a usual practice. For descriptive statistics we calculated simple frequencies for all variables. We initially performed chi-square tests to assess bivariate associations with demographic factors of age, gender, practice setting (i.e., urban, rural, suburban) or practice type (i.e., private practice, community health center, etc.). We then examined differences in agreement regarding in which situations a drug test should be recommended and self-reported practice parameters across professional groups, while adjusting for the potentially confounding demographic factors. We subsequently conducted backwards selection logistic regression analyses for each attitude and practice measure, and included professional group and all significantly associated demographic factors in each model. In backwards selection, we eliminated covariates that had a significance level of p > .10. We report adjusted odds ratios and 95% confidence intervals for the professional group variable. Results Table 1 presents the demographic characteristics of our sample. Respondents were predominantly male (54%), diverse in age, and from urban and suburban locations. Slightly over half of the sample (52%) worked in group practices. There were no significant differences in age among specialty groups. Family physicians were more likely to be male (p < .0001) and practice in rural settings whereas adolescent providers were more likely to practice in urban settings (p < .0001). Physician agreement regarding when to recommend a drug test was substantially associated with gender, age and practice type; usual physician practices regarding how they proceed when a urine test is positive or negative were substantially associated with age and gender, and we therefore controlled for these variables in subsequent analysis. Discussion of home drug testing was strongly associated with both gender and practice group. Other demographic variables were not substantially associated with either agreement or practice parameters and were not included in further analyses. Screening in schools Eighty percent of all respondents and 93% of adolescent medicine providers disagreed or strongly disagreed with the Office of National Drug Control Policy’s (ONDCP) recommendation that all adolescents be drug tested at school. Ninety-three percent of respondents disagreed with performing urine drug test screens on all teens presenting for primary care and this did not differ significantly among the three specialties. Home drug testing Female physicians from all three groups had three times greater odds (OR = 3.52, 95% confidence interval [CI] 1.87–6.63) of having discussed home drug testing with adolescent patients and their families compared to male physicians. Adolescent medicine providers had 10 times greater odds compared to family physicians (OR = 10.0, 95% CI 4.4–25.0) of having discussed home drug testing with adolescents and their families, even after controlling for gender. Physicians who discussed home drug testing did not necessarily recommend this procedure; only 9% of physicians who discuss home drug testing with teens and their parents recommend it “often” or “sometimes” for their patients. Guidelines Fifty-nine percent of physicians did not know whether their professional society had published policy guidelines regarding adolescent drug testing (the AAP does have published policy guidelines that address the ethical issues of adolescent drug testing but do not address the practical issues of clinical utility [8], the AAFP does not have specific adolescent drug testing guidelines but has published a general drug testing guide [9]). Of those who are aware of professional society guidelines (n = 128), 90% find them “very” or “somewhat” useful. Discussion Among physicians in this study, 1) the majority do not recommend drug testing adolescents as a screening procedure, 2) there is a wide range of opinion regarding when to recommend a drug test as part of an assessment for an adolescent patient, and 3) there is little consistency regarding how to proceed when a drug test from an adolescent patient is positive. These findings suggest that clinical practice guidelines that help physicians decide when to order a urine drug test and how to proceed with positive results would be useful. Overall, the physicians in our survey did not recommend urine drug testing as a screening procedure for unselected populations, whether in schools or in primary care clinics, or at home. Parents, school administrators and policy makers should be aware of this finding. Few physicians overall discuss home drug testing with adolescents and families, although women physicians may be more likely to discuss this topic than their male colleagues. This finding may be related to previous work that has shown that women physicians have longer primary care visits than males [13], and may include more topics for discussion. Of physicians who did discuss home drug testing, very few recommended this procedure. When a teen presents to a physician’s office with signs and symptoms consistent with drug use, drug testing a competent minor against his or her wishes presents a clinical and ethical dilemma, with physicians caught in the middle. Overall, our respondents tended to be cautious in recommending drug tests against an adolescent’s wishes, with slightly less than half agreeing with the recommendation for a drug test in any of the clinical situations described by the survey instrument (i.e., if a parent felt strongly that the child was using drugs and denying it, if it was required to return to school, if the physician thought s/he was using [even if the parent(s) did not have concerns]). However, the nearly equal distribution of responses in our survey suggests that there is little consensus regarding the overall utility of drug testing in these situations. Family physicians are more likely to recommend a drug test when requested by a parent or a school than adolescent medicine providers. We believe these findings may suggest that family physicians relate differently to their adolescent patients, and to their parents (who may also be patients) than adolescent medicine specialists. Very few of our respondents, from any specialty, agreed that they would perform a drug test on an adolescent without his or her knowledge. A physician may be faced with managing a patient with a positive drug test whether or not s/he would have recommended the test. Most physicians in this study reported that they assess all or most adolescents with positive drug tests in their office; however, general pediatricians were much less likely to perform further assessment and much more likely to make a mental health referral than adolescent medicine providers or family physicians. We would expect that family physicians and adolescent providers would have much more experience with drug use and drug problems than pediatricians, because adolescents comprise a relatively small proportion of pediatric patients. This finding, although not surprising, has significant implications. Drug and alcohol use are common among American adolescents. In 2004 almost half of all high school seniors had ever used marijuana, and nearly three-fourths had used alcohol [14]. Referral of teens for any drug or alcohol use could overwhelm the mental health care system. Furthermore, 7% of physicians who would not be able to evaluate a teenager for drug use also would not be able to find an appropriate referral, leaving a population of teenagers without access to any form of evaluation for drug use through the health care system. Professional societies may be helpful in establishing clinical practice guidelines. Few physicians in this study were aware of professional society guidelines regarding adolescent drug testing, although most clinicians who are aware of these guidelines do find them helpful. We anticipate that the publication of clinical practice guidelines would be helpful to physicians interested in this topic, but would not reach the majority of physicians who provide primary care for adolescents. In this regard, professional societies might also consider increasing the visibility of any practice guidelines that are published by offering training opportunities such as workshops at national meetings or Internet materials. Limitations This study has a number of limitations. First, our response rate of 43%, although similar to other recently published reports of physician surveys [15], [16], [17], [18], [19], is somewhat low. This finding is likely related to the unexpectedly high rate of invalid contact information in the professional society databases, as well as barriers common to all physician surveys, including limited physician time for nonpatient care duties, survey fatigue, and screening of materials by office staff. We created a new survey instrument because we are not aware of any other tool that was designed to measure the practices and agreement parameters of interest. We used forced-choice questions, which did not give us the opportunity to explore agreement parameters further. Although we did give respondents the opportunity to expand on their answers, few did. We do not know why the majority of physicians do not agree with screening general populations with urine drug testing, and further exploration of this topic in a future project may provide useful information for policy makers. A theme that could be explored is whether physicians believe the sensitivity of drug testing is too low to be used as a routine screening test. A previous report by our team noted that even teens with serious drug problems would have negative screens in a variety of situations (i.e., when a teen is using a drug not included on the routine panel, if a testing “window is missed” or if a teen defeats a drug test by any of a variety of methods) [4]. Another theme for future study could be whether physicians believe that drug screening programs violate adolescents’ rights. Policy makers would need this information in order to determine how they might adapt programs to get physician “buy-in.” We are also unable to determine why individual physicians would or would not recommend a drug test in the situations presented. Previous work has demonstrated that although most primary care physicians order urine drug screens, only a minority use recommended practices, and the majority made factual errors regarding interpretation of the results [10]. It is possible, therefore, that some physicians make decisions regarding when and how to use drug testing based on incorrect information regarding the procedure. This case would lend further support for our conclusions regarding the need for clinical practice guidelines and more educational opportunities to standardize best practices. Conclusions Overall, our findings suggest that there is little consistency in physician practices regarding indications and follow-up of drug tests, and the majority of physicians disagree with urine drug testing as a screening procedure. Furthermore, a significant proportion of primary care physicians do not assess teens with positive drug tests, and the majority of physicians refer most or all teens with a positive drug test to a mental health care provider. We believe that professional societies should create clinical practice guidelines regarding when and how to use urine drug testing with adolescent patients and should provide educational opportunities in this area. Acknowledgments This study was supported by Grant 049207 from The Robert Wood Johnson Foundation Substance Abuse Policy Research Program. Other support was provided to J.R.K. by Grant K07 AA013280 from the National Institute on Alcohol Abuse and Alcoholism and Grant 1 T21 MC 000122 from the Maternal and Child Health Bureau. The authors would like to acknowledge Dr. S. Jean Emans for reviewing this manuscript. References [1].
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a Department of Pediatrics, Harvard Medical School, Boston, Massachusetts b Division on Addictions, Harvard Medical School, Boston, Massachusetts c Center for Adolescent Substance Abuse Research, Children’s Hospital, Boston, Massachusetts d Division of General Pediatrics, Children’s Hospital, Boston, Massachusetts e Division of Adolescent/Young Adult Medicine, Children’s Hospital, Boston, Massachusetts  Address correspondence to: Dr. Sharon Levy, Center for Adolescent Substance Abuse Research, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115.
PII: S1054-139X(05)00528-8 doi:10.1016/j.jadohealth.2005.11.023 © 2006 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved. | |
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