Observed Urines

Here is what the Federal Regulations say concerning urine testing:

Testing for Drug Use

(1) Programs use drug and alcohol screening and testing as aids in monitoring and evaluating a patient’s progress in treatment.
(2) All treatment personnel in a medication-assisted treatment program understand the benefits and the limitations of toxicological testing procedures.
(3) Programs collect all urine or other toxicological specimens in a therapeutic context that suggests trust and respect, and minimizes falsification. Reliance on direct observation, although necessary for some patients, is neither necessary nor appropriate for all patients.
(4) Clinicians should determine the drug-testing regime by analyzing community drug-use patterns and individual medical indications. Testing may include opiates, benzodiazepines, barbiturates, cocaine, marijuana, methadone (and its metabolites), amphetamines, and alcohol, but is not limited to these substances.
(5) It is strongly recommended that barbiturates and alcohol be included in drug screening and testing panels. Alcohol is the most widely used mood-altering substance in the United States, and barbiturates are often prescribed for detoxification and chronic seizure disorders. Detection of barbiturates or alcohol is important in ongoing assessment, treatment planning, and medication management.
(6) Workplace Standards established by the Center for Substance Abuse Prevention are not appropriate for patients in the treatment context. The procedures and methodology for Workplace Standards employ a forensic approach that is entirely different from the therapeutic approach to treatment used in the clinical setting.
(7) Program staff addresses results of toxicology testing with patients promptly. Programs document in the patient record both the results of toxicology tests and followup therapeutic interventions.
( After the patient’s initial admission drug testing, clinicians determine the frequency of toxicological testing by evaluating the clinical appropriateness for each patient in relation to the patient’s stage in treatment.
(9) The results of toxicological tests assist clinical staff in making treatment decisions regarding take-home medication privileges; however, clinicians do not base decisions about take-home medications or discharge solely on toxicology test reports.
(10) Clinicians rapidly intervene to address the disclosure of illicit drug use, a positive drug test, or possible diversion of opioid medication, as evidenced by lack of opioids or related metabolites in drug toxicology tests.
(11) Clinicians consider confirming the results of drug screening tests with additional testing. Treatment programs establish procedures for addressing potentially false positive and false negative urine or other toxicology test results following principles outlined in TIP 43, “Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs” (CSAT 2005, chapter 9).

From The Administrator:
You need to check your State Regulations because if they are stricter then you have to abide by them.

Here is a Policy Statement from NAMA Recovery that may be of interest to some on this subject....



As methadone programs have become more punitive the policy of observing the patient while giving a urine specimen has become more common. Fortunately, these policies have remained the exception, as the majority of programs do not find the need to scrutinize their patients. Patients state that it is of up most importance to be treated with dignity by their program and demeaning policies only promote low self-esteem and self worth.


Respect and dignity are necessary in order for the program to develop a therapeutic alliance with a patient. Patients enter treatment with feelings of failure and low self-esteem. One of the important features of recovery is regaining one's self respect and worth. Therefore, programs that treat patients as intractable and dishonest will find that patients meet these expectations. When this occurs it only confirms to program staff that their original perception was correct and that patients are incapable of conventional behavior. However, programs that treat patients as trustworthy and with respect will have patients that grow into responsible individuals. These patients view the program as friendly and there to help them. And these patients will usually seek help if they develop an ancillary drug problem before a urine specimen is asked of them.

Most certainly some patients will take longer than others to seek help. The point is that when patients are allowed the opportunity to seek help, and receive it with compassion and dignity they will strive for it. Patients will respond to this kind of treatment positively. The program staff will believe that they are providing a service to the community as well as helping people get their lives back together.

Some programs believe that the only way to know if a patient is using drugs is through urine tests. Programs that provide quality treatment only use urine testing as one of many therapeutic tools. This is because urine tests are not perfect and there will always be false positives caused by medications or foods. And there are ways that tests can be fooled despite enormous efforts to protect the procedure. Thus a program that wants to provide compassionate treatment will begin to assess if such efforts are actually worth it. Strategies to insure that urine specimens are correct not only have an impact on all the patients, but many will find these additional procedures humiliating.

Particularly the staff is affected in negative ways and typically counselors are selected to observe urine tests. By appearances this choice may seem logical, however it really works against quality counseling and treatment. Over time the counselor's faith and trust in patients will become corrupted because their job is to catch the cheaters. Most counselors will not be able to septe their role of catching cheaters from helping their patients. Their view of patients becomes pessimistic and they spend their time calculating ways to catch the cheaters who are few in number. As helping staff they have become useless and in some instances can actually be harmful to patient care.

Supervising staff can also be affected. They begin to seek more ways to control patients and decisions regarding individual patient incidents become more severe. As the atmosphere of the program changes the remaining staff begins to see patients as irresponsible, manipulating and unable to maintain a stable life. A barrier has been created between the staff and the patients that will be difficult to overcome. The program has gone off course and forgotten their first mission and mandate was to help patients.1


In recent years state and federal courts have decided against the use of cameras in department store fitting rooms and other areas where privacy is expected. While some programs may believe video cameras to be less invasive, these devices are no less damaging that an individual standing in the bathroom. Patients would not only be concerned about the time that they are giving the specimen but also what happens to the film. The use of cameras have no place in monitoring urine specimens because there is no way that any program can guarantee absolute privacy for patients. It would be necessary to guard the camera because any missing film could be the source of litigation regarding patient privacy.


For a program to monitor urine specimens it is imperative that special staff be hired so that counselors and other helping staff are not placed in the position of being corrupted. This requires one man for the male patients and one woman for the female patients resulting in added expense. Assigning current staff does not help to reduce the cost. As noted above observed urine testing has a definite psychological effect on staff but there is also a monetary impact. When counseling or other staff are used to observe urine tests positive contact with patients is reduced and the result is a reduction in the quality and quantity of their work.


When methadone treatment was started by Drs. Dole and Nyswander supervised urine testing was never used because it was not necessary. Dr. Nyswander was responsible for creating the philosophy of the program and it was her belief that the program's role was to rebuild patient's esteem and feelings of self-worth. There was no place in the program for procedures that interfered with the therapeutic alliance that needed to be developed between patient and program. To this day Beth Israel Medical Center does not observe urine specimens and will ‘not’ even if it is requested because such procedures are demeaning to patient self esteem. But more important was the rationale for not supervising urine testing. Drs. Dole and Nyswander trusted patients and always told them that if they needed help to come and tell their counselor. And it worked because the patients trusted the program with their treatment. The program made every effort to keep the patient functional and preserve their self-esteem. Patients never experienced punishment for displaying symptoms of their disease and that contributed to patient honesty and program integrity.


Programs that utilize punitive policy need to re-evaluate their purpose for providing treatment. Are they treatment professionals whose purpose is to return people to society as productive individuals or are they wardens of the community whose job is to control the unruly. In efforts to reduce work for the staff has the program gone off course. Program administrators need to go back in history to re-discover the success of the early Dole-Nyswander program whose first mission was building self-esteem and returning people to society as productive members. Some program in implementing policy have lost their integrity and forgotten that their first directive is to the patient and providing quality treatment with dignity and respect.

Note:
The handbook of one multi-site program that treated several thousand patients contained a total of 14 pages devoted to instructions for patients both male and female on submitting a supervised urine specimen. The handbook had no mention of methadone as a medication or what a patient could expect from treatment.


*** A comprehensive Index of Policy Statements, Educational Series and other publications from the National Alliance of Methadone Advocates, Inc. dba National Alliance for Medication Assisted (NAMA) Recovery can be found here: http://methadone.org/library/index_nama_publications.html