Drug abuse and drug trafficking have been called the great plague of modern society, and not without reason. Law enforcement agencies report that an increasingly large proportion of crimes of violence, break and entry, theft and smuggling are due to addiction and drug trafficking. Announcements of police impoundment of large amounts of illegal drugs and the discovery of makeshift laboratories where they are refined or manufactured are now almost daily occurrences. Addiction treatment facilities are burdened with an ever-increasing load of drug and alcohol affected patients. Social workers wrestle with the complexities of drug and alcohol-related problems of families, and government agencies launch widespread anti-drug and alcohol campaigns in an effort to reverse the situation. The cost in terms of human suffering, in the diversion of scarce financial and professional resources and in the loss to national productivity is staggering.

The workplace is not exempt from this phenomenon. For decades alcohol abuse has been recognized as a serious problem for industry, but only recently has drug use been recognized as having serious effects on job performance. The results are, in all respects, similar to those produced by abuse of alcohol: lowered productivity, increased absenteeism, endangered security, and increased accident rates.

Some alarming figures support these facts. The North Carolina-based Research Triangle Institute has estimated the cost of drug abuse to the U.S. economy in 1983 to have been $60 billion, triple the amount for 1980. Since 1975, more than 50 train accidents have been caused by drug or alcohol impaired workers. In Canada, the Council of Safety Associations has observed that substance abusers have triple the absenteeism rate of other workers, triple the rate of late arrival for work, and twice the number of accidents considered to be normal for the type of work they are doing.

In an attempt to respond to these problems, an increasing number of companies in North America have introduced employee drug testing programs. Currently, about half the Fortune 500 companies screen job applicants for drug use. Some companies have, with little or no planning, introduced mandatory drug screening of the entire workforce. The results of this approach have often been as bad or worse than the situation it was intended to reverse, with expensive and lengthy legal battles, acrimonious labor-management conflict, and disastrous decline in worker morale and productivity. Many firms now contemplating the introduction of drug screening are taking a long second look and are approaching the issue with due caution and sensitivity.

The most fundamental question concerning screening for drug use at the workplace is whether it can be truly effective in reducing or reversing the problems that drug abuse creates. Studies carried out by the U.S. Navy and Army and by companies that have screened their employees for drug use have found that a carefully planned screening program is associated with significant accident rate reductions. It is not completely clear whether drug testing acts simply as a deterrent which causes modification or reduction of use, or whether it simply weeds out drug users, but the evidence confirms that employee drug screening does have the capability of making the workplace safer and more secure. The problem which a company must face is to develop a program which effectively addresses its particular problems without unduly ruffling the feathers of those concerned. Company employees, the occupational health service, company management and legislative authorities each have their own particular concerns which must be addressed.

Pathological use of alcohol and other drugs is characterized by at least one of the following: intoxication throughout the day, inability to stop using the substance, repeated attempts to control its use, a daily need for the substance or continual use despite serious resulting illness. Table 25.1 presents clinical features of the abuse patterns of several common days. Physical dependence may be recognized from withdrawal signs. It should be appreciated that alcoholism and abuse of alcohol are still by far the most widespread of drug disorders. All sources of data confirm this. Unfortunately, at the present time, there are no reliable predictors as to who will become an alcoholic.

This chapter outlines the many factors which must be considered in developing and introducing a workplace drug screening program and concludes with the presentation of a stepwise process which can be used as a guideline for company planning.

Table 25.1. Specific Drugs of Abuse.

In light of the problems caused by drug use this may seem at first glance to be a frivolous question. Yet on examination there are a number of possible reasons why an employer might want to screen his workers for drugs and, in fact, there may be more than one ultimate goal. These reasons may be conveniently grouped under two headings: those which have a moral or altruistic basis and those which have a job function or operational basis. It is neither uncommon nor necessarily undesirable for a moralistic viewpoint to underlie and to some degree shape the approach used in a drug screening program initiated for operational reasons, but it is important that these two reasons be quite clearly identified in the mind of the employer if misunderstandings and misapplication of screening are to be avoided. In addition, there may be actual or perceived legal obligations which impinge to some extent on these reasons, important aspects of which will be addressed later.

Drug screening programs undertaken for either of the two fundamental reasons may be intended as a solution to an ongoing problem (reactive program) or as a measure to guard against a problem which might otherwise occur (preventive program). Reactive programs, if successful, may be perpetuated as preventive programs.

The following are a few examples of reasons employers start a drug screening program, classified as above.

1. Practical-Preventive. - Drug use in the local community is high and the employer wants to guard against accidents or poor productivity.

 

2. Practical-Reactive.
1. Accident rates are unacceptably high and drug use appears or is known to be associated with their occurrence.
2. Thefts at work are becoming a problem and drug use is suspected as a cause.
3. Absenteeism has increased and productivity has decreased.

Drug use is suspected to be a cause.

These examples illustrate the motivations which underlie drug screening programs. In practice, drug testing should always be undertaken primarily for clearly defined operational reasons. The moral aspects should be of secondary importance in a drug screening program, with a strictly supportive role. Following this principle will assist the employer in avoiding serious problems in screening workers for drug abuse.

The reasons chosen dictate who will carry out the tests, which workers will be tested and how the testing will be done. For example, if drug use screening is done to counter theft at work and not for health and safety reasons, it should not be carried out by health personnel. The prevention of theft is the responsibility of security personnel and the type and timing of the tests and the selection of workers for testing will differ greatly from testing done for health or safety reasons. The reporting of test results and the subsequent disposition of workers found to have positive results will also differ depending on whether testing is done for health or safety reasons. If the occupational health service becomes associated in any way with security checks and with disciplinary action, it immediately loses credibility to workers as an objective resource to which the worker can bring personal health problems with confidence that the information will be handled in a discrete manner.

In establishing a rationale for undertaking drug screening, the employer should also be cognizant of the limitations of drug analysis. These limitations will be presented later, but it is important to realize that drug screening alone will not reveal whether an individual is addicted to a drug, whether he or she will suffer future functional impairment or if the use of drugs will worsen. Furthermore, studies have found no simple correlation between casual off job use of drugs and safety on the job.

Assuming that the screening test used is valid and specific, drug testing may reveal that a specific drug has been used, but it cannot say why. Employers need to be aware that there are several relatively "benign" reasons why an individual may take an addictive drug: as an act of rebelliousness, out of curiosity, for pleasure, as a means of identification with the counterculture, or for quasireligious experience. True drug abuse, however, always indicates the presence of a significant underlying condition which may or may not be work-related. These conditions may be anxiety, depression, chronic feelings of inadequacy, uncontrollable resentment or anger or social disruption which may not yet be overt. These are not simple matters that can be made clear by drug screening alone. The wise employer will avoid attempting to solve the drug related problems of society through drug screening at the workplace.

The employer's reason for introducing a drug screening program determines in large part the workers who should be selected for screening. However, this determination is constrained by a number of ethical and legal obligations and by certain technical limitations to drug testing. The employer must also consider the possible consequences to workforce morale should drug screening be applied in what his employees interpret to be an unjust manner. Far from improving or maintaining productivity, a poorly applied drug screening program could well have the opposite effect as will be shown.

Before examining the ethical and legal constraints involved, it is worthwhile listing the possible choices for selecting workers for testing:

1. All employees, without exception.
2. Workers directly involved in "hazardous" operations or who are at greater than average risk of injury.
3. Operators of equipment which, if improperly used, could endanger the health or safety of co-workers or the public.
4. All applicants for employment without exception.
5. Applicants who apply for "hazardous" jobs.
6. Applicants who apply for jobs which, if improperly carried out, could endanger the health or safety of co-workers or of the public.
7. Workers involved in a workplace accident which is under investigation.
8. Workers who show deficits in work performance and who are suspected drug users.
9. Workers suspected of workplace theft.
10. Workers suspected of drug dealing at work.
11. Applicants who apply for jobs which, if improperly done, could have grave financial or legal consequences for the company or which could seriously damage its reputation.

These may be summarized in four categories: all current employees, selected current employees, all work applicants, and selected work applicants. The three final groupings (items 9, 10 and 11 above), not having a basis of either health or safety, are not discussed further. However, it must once again be emphasized that occupational health personnel should not be involved in drug screening activities where neither health nor safety are the prime considerations.

Screening all employees or all job applicants without exception has the advantage of being completely non-discriminatory, but it is almost certain to be wasteful in terms of the cost-benefit ratio. For a great many types of work, occasional and moderate use of some drugs away from the workplace (alcohol, for example) has no noticeable effect on performance on the job. Furthermore, unless skillfully handled, such a program runs the risk of being perceived simply as the employer's moral crusade. It has the effect of announcing to job applicants in particular that drug use is considered to be a serious detriment to an employee, but because it is a "shotgun" approach and is not tied to actual workplace hazards, the message is largely moral: "We don't want drug users as employees because we don't agree with drug use."

Selecting workers for drug screening who are at greater than normal risk of injury or who could endanger their co-workers or the public if they worked while intoxicated, has the advantage of concentrating effort where it has the potential of being most useful. Furthermore, it lacks the moral overtone presented by universal screening. More important in many ways is the fact that drug screening of these workers fulfills the principle that involuntary worker health examinations should be specific to the hazards of the job they perform.

Preplacement screening of applicants for hazardous jobs may have a deterrent effect, but at the time of writing studies into this aspect are singularly lacking. It is possible that deterrence is sufficiently served through notice that applicants hired for these particular jobs must submit to periodic or regular drug screening while so employed.

Reports on the extent of drug and alcohol involvement in industrial accidents is extremely variable. Some studies report very high rates and the publicity surrounding spectacular disasters where workers were intoxicated convey the impression that drug or alcohol use are almost invariably associated with workplace accidents. However, some studies have reported surprisingly low correlations. It is probably safe to say that in communities where drug or alcohol abuse is believed or known to be prevalent, it would be wise for an employer to have a policy of screening workers for drug or alcohol use where such workers have been involved in a workplace accident which is to be investigated.

Workers whose performance is below what is reasonably expected by the employer and who are suspected of being alcoholics or drug users should be referred for medical assessment. The occupational medical service can advise whether drug testing is appropriate on the basis of their examination of the worker in conjunction with the referral information.

Although ethical issues for occupational health practice generally is discussed in Chapter 30, this section will address issues unique to drug screening. The legal issues concerning worker drug testing are complex. Some aspects are straightforward but more remain unclear and unresolved. Employers in many parts of the United States are confronted with threats of litigation or are engaged in court battles with disappointed job applicants or disgruntled employees who have been the subjects of drug testing. Workers have been placed in situations where they feel their employer has discriminated against them or has invaded their privacy through mandatory drug testing. Legal assistance is beyond the means of many workers and, from their point of view, there seems little they can do if they want to get or keep a job which is denied them because of the result of a drug test.

On the other hand, employers find themselves in a "Catch 22" situation with OSHA, state or provincial laws requiring them to maintain a healthy and safe workplace while guarantees of individual rights and freedoms prevent them from taking action which would appear to offer the opportunity toward achievement of that goal. Situated between the employer and his workers is the occupational health practitioner, performing his customary balancing act, juggling the legal and ethical issues, desperately trying to avoid falling to one side or the other while inching along his professional tightrope.

The use of chemical tests on workers is largely unregulated, so worker opposition to drug testing consequently must rest on basic constitutional guarantees, none of which were framed with drug testing in mind. The principal guarantees to which they refer are the right to privacy of the person, the right not to be subject to unreasonable search and seizure, the right to due process of the law, and the right to equal protection under the law.

It is clear that the individual's right to privacy is not absolute. State interests can over-ride it. Nevertheless, there are laws in some states which support privacy by prohibiting employers from inquiring of any worker or job applicant whether he has ever been arrested on a drug-related charge.

Drug screening results retained in the worker's occupational medical file have been considered by the courts as remaining private. A specific piece of legislation, the Drug Abuse Office and Treatment Act of 1972, applies to federal facilities, agencies and federally funded facilities. This Act requires a worker's written consent for release of personal information contained in the employment medical record. An exception is made for situations in which release is necessary in light of the purpose for disclosure. However, an attempt must first be made to obtain a court order for the information's release. The Act also prohibits the use of worker medical records to verify that a worker is taking part in a rehabilitation program or to deny him employment.

Workers in some states have sued their employers successfully for unlawful invasion of privacy through mandatory drug testing even though the workers signed consent forms when hired. Nevertheless, courts have generally found drug testing not to be an unwarranted invasion of privacy when carried out in a reasonable, confidential and non-discriminatory manner for legitimate business reasons. They have found employee refusal to undergo testing to be legitimate grounds for job termination or other disciplinary measures by the employer.

The 4th Amendment of the U.S. Constitution guarantees protection against unreasonable search and seizure. A wise employer would avoid random testing of workers until advance warning is given that testing will be done on a random basis and possessing recorded evidence that sufficient symptoms and signs were present to justify the test. U.S. employers do have a broad legal right to investigate suspected violations of their rules and workers have a duty to cooperate in such investigations. The courts have supported this. However there are alternatives to drug testing which may be considered by the employer. The advantages and disadvantages of these are discussed further on in this chapter.

Equal protection under the law is guaranteed under the 14th Amendment to the Constitution. Employers can reject job applicants who fail a job-related examination of any kind, but all applicants must be examined in the same way. If only selected applicants are tested for drug use, the onus is on the employer to present valid reasons why some are tested and other are not. Under U.S. federal and some state employment discrimination laws, drug and alcohol addictions are considered to be handicaps. Employers who are subject to these laws cannot refuse to hire and may not fire or discriminate against drug or alcohol dependent workers provided that they can do their job with "reasonable accommodation" (see definition) on the part of the employer.

Canadian law is similar to U.S. law in its general effect on drug testing in the workplace, but it derives from the Canadian Charter of Rights and Freedoms, the Canada Labour Code, the Canadian Human Rights Code, provincial human rights codes, and collective agreements between labour and management. The Canadian Charter of Rights and Freedoms is similar to the U.S. Constitutional Amendments in that it applies to governmental relations but not to private employer relations. Section 8 of the Charter, like the 4th Amendment to the U.S. Constitution, guarantees the individual the right of protection against unreasonable search and seizure. Therefore a demand by an employer for a urine or blood sample for drug testing, made without substantive grounds for carrying out such a test, might be interpreted as a contravention. Section 11c prohibits the compulsion of an individual to provide self-incriminating evidence. Submission of a blood or urine sample which is positive for a drug or its metabolite may, on the face of it, contravene this section. Unfortunately, the Charter was enacted recently, in 1981, and at the time of writing the matter of drug testing in relation to the Charter has not been tested in court.

Of more immediate relevance to drug testing in Canada are the federal and provincial human rights codes. These codes, administered by appointed commissions which operate independently of the normal court system, consider drug and alcohol addictions to be physical or mental disabilities and specifically prohibit employers from discriminating against disabled workers and job applicants. Action taken to summarily dismiss or refuse to hire a disabled person is not permitted unless the employer can clearly show that the disability adversely affects job performance or safety. Positive drug test results must be used to direct workers to rehabilitation. In addition, samples obtained for testing for particular drugs must not be used for the detection or measurement of other substances or metabolites unless they too are specifically applicable to job performance or safety. If challenged, the employer must provide scientific or expert evidence of the need for such tests.

The Canadian Human Rights Commission has prepared the following guidelines for federally regulated employers who want to test their employees and job applicants for drug use:

1. The employer must show that use of the drug being tested for has a detrimental effect on the worker's concentration, ability to operate equipment, perform tasks efficiently and safely, or will increase absenteeism, accident rates or staff turnover.
2. The employer must have reasonable grounds, based on objective evidence, that drug use is a problem at his workplace and that it reduces performance or safety.
3. The drug test must only be used to screen for the targeted drug or its metabolite and the test used must be recognized and valid.
4. If the test result is positive, the employer must make reasonable accommodation for the worker.

Unfortunately, these legal guidelines are complicated by ethical considerations. Not only are employers constrained by the customary ethics of business practice, but they are also affected by the professional ethics of the medical, nursing and laboratory personnel they employ or with whom they contract to carry out their drug testing program. The American Occupational Medical Association (AOMA) has produced a set of ethical guidelines for physicians who are involved in worker drug testing. Unfortunately, these guidelines may unwittingly destabilize the delicate balance the physician must maintain between the demands and desires of the employer and the employed. Principle objections concern the use of imprecise terminology such as "reasonable business necessity" (which is offered as a legitimate ethical basis for drug screening) and the inherent contradiction of advising an employer to obtain employee consent for mandatory screening.

What ethical obligations fall to an employer who receives a positive drug test result on one of his employees? An interdisciplinary panel of lawyers, businessmen and labor representatives at a 1986 workshop sponsored by the U.S. National Institute on Drug Abuse agreed that the employer should provide an opportunity for the worker to enter a drug education program or, if appropriate, to enter a drug rehabilitation program, to offer alternative employment (if available) and to consider the worker for full reinstatement upon successful completion of his program.

Although important legal issues in testing workers for drug use remain in dispute, employers clearly face potential liability in the following circumstances:

1. When negligence occurs in the collection or handling of blood or urine samples.
2. When improper disclosure is made of positive test results.
3. When testing or testing procedures fail to comply with collective bargaining agreements.
4. When the employer fails to take action to maintain workplace safety when test results are positive.

Negligence in the collection of samples or in sample handling can result in legal action against the employer if it results in damage to a worker's reputation or livelihood. Negligence will also cause distrust and disparagement of the program among workers and will lower employee morale. The specific requirements to avoid negligence in handling samples will be described below in conjunction with the technical aspects of drug testing.

In summary, one can say that worker drug testing is legal under certain circumscribed conditions, but the employer must plan the program with extreme care to minimize the likelihood of legal challenge. Complete protection from employee- or job applicant-initiated lawsuits cannot be expected until there is further guidance from the courts and more precedents established under case law. Until the appelate courts provide guidance or the Supreme Courts of the states, provinces, and federal governments make final determinations, employers will continue to face uncertainty about their legal standing with regard to drug testing. Any employer who contemplates introducing drug testing into his workplace should first obtain expert legal counsel. In the final analysis, the employer must weigh the risks taken in drug testing against a realistic estimation of the ability of testing to improve worker performance and safety.

The chemical and mathematical aspects of drug testing do not provide a firm basis for confidence in decision making. The technical aspects, like the law, contain important elements of uncertainty and illusion. Three topics deserve examination and appreciation in the technical area: the drugs themselves, the tests available to detect and quantify the drugs, and the requirements of sampling and laboratory analysis. Table 25.2 describes the common screening techniques used for drug detection.

Often, the first evidence that drug abuse is a problem is the observation of social or occupational disruption. This may appear as unusual irritability or mood swings, inexplicable work absences, problems with the law, family or friends, or decreased attention to safety and work productivity. Each drug has its own particular effect during the "high" and another during withdrawal. An overview of specific drugs of abuse has been provided in Table 25.1. All possible effects of all individual drugs cannot be committed to memory, but it is useful to appreciate how addiction to a drug can affect worker safety and productivity in a particular operation.

A single test for any drug without other evidence simply cannot justify the diagnosis of addiction. The diagnosis should be left to the physician, who will take into account the results of a physical examination, laboratory findings and information on the behavioral characteristics of the individual in order to reach a diagnosis.

This page represents Tables 25.2

Table 25.2 Characteristics of Screening Tests for Drugs in Urine

* Most commonly used methods

The results of drug testing can have profound effects on the lives of the individuals tested. The tests used must be of the highest reliability and must have the capability of withstanding rigorous examination in court. In practical terms this means that the tests must accurately identify the drug or drugs tested for, must quantify the amount of drug present, and must be supported by documentary evidence of an unbroken chain of custody. Before proceeding to closer examination of these characteristics, it is necessary to have an appreciation of the testing process.

First consideration must be given to the predictive value of testing; in other words, to the determination of what percent of the test samples found to contain a drug actually do contain the drug. This is expressed as the percent true positives and depends on how good the test is in detecting only samples containing the drug (specificity) and how good it is in detecting all samples which contain the drug (sensitivity). It also depends on how many of all the samples contain the drug.

As an example, let us say an employer uses a test which will pick up 99 out of every 100 samples which contain the drug. In other words, it misses 1 out of every 100 positive samples. It therefore has a sensitivity of 99%. In addition, let us say the same test will identify 100 samples as containing the drug, whereas only 90 of them actually do. This test therefore has 90% specificity.

Now, let us apply this test to 10,000 workers of whom 100 are in fact using the drug out of 100. 99 of the drug users would be correctly identified by the test (99% sensitivity), but 990 of the 9900 non-users would also but incorrectly test as positive (90% specificity). The predictive value of the test in this situation is 99/990 x l0 percent, or 90% of the positive results would be false! In such a situation, this test would be worse than useless because it would incriminate the innocent 10 times more often than the guilty.

If the same test is applied to another population of 10,000 workers in which there are 1,000 drug users (a tenfold greater prevalence), the predictive value of the test can be shown to be 52% (which means that 48% of the positive results are false). The predictive value of a drug test thus increases with the proportion of drug users in the population tested. Looked at another way, the fewer the number of drug users in the tested population, the poorer the predictive value of the drug test. This is another reason to avoid drug testing where a serious problem does not exist.

This phenomenon also emphasizes the necessity for retesting workers whose tests are found to be positive. In the first example, the test showed that one worker in ten was using drugs, when in fact only one in a hundred were actually users. In the second example, it showed that one in ten workers was using drugs, but half of them were innocent workers incorrectly identified. Obviously, an employer basing disciplinary action only on the basis of the tests in either of these situations would be courting legal disaster. For this reason drug testing must always be repeated when a positive result has been obtained. An initial screening test should be used with the objective of detecting the presence of the drug or drugs of interest, followed by a more precise confirmatory test using a different analytical method. Some of the confirmatory tests for drug identification are described in Table 25.3.

Whether a test will be reported or accepted as positive or negative depends on four factors. The first, the test's sensitivity, has been discussed. The more sensitive the test, the greater the proportion of positive samples that will be detected. Since more tests are quantitative in nature (that is, they measure the concentration of the drug in the sample), the definition of "positive" depends not only on the test's sensitivity, but also on the cutoff point established by the employer as the maximum level acceptable. For some drugs such as heroin or cocaine the employer will usually establish a zero level cutoff, but for alcohol the employer may be willing to accept blood levels of up to the legislated level of impairment, somewhere in the range of 50 to 85 mg/dl.

The problem of the cutoff level is the second factor determining whether a test result will be positive or negative. Complicating determination of an appropriate cutoff level further is the need to consider the length of time since the drug was last used. Drugs and their metabolites may remain in the body for varying lengths of time. In some cases, such as This page represents Table 25.3

Table 25.3 Characteristics of Confirmatory Tests for Drugs in Urine

GC = Gas Chromatography

GC/MS = Gas Chromatography/Mass Spectrometry

HPLC = High Performance Liquid Chromatography

marijuana, traces remain for several weeks after use. By contrast, cocaine derivatives remain detectable in body fluids for only one to three days. Table 25.4, reproduced by courtesy of the AMA Council on Scientific Affairs, presents the time limit for detecting drugs in urine samples and the smallest concentration of each which can be reliably detected. Variables such as these create problems in analysis. A zero-level cutoff in some of these situations may product results which reflect drug use confined to the worker's leisure time. Applying disciplinary action might then be seen as intervention on moral grounds against personal activity which has no effect on work performance.

The two factors of drug dose and frequency of drug use are closely related to the time of testing and to the cutoff level. The higher the dose used, the more likely it is that the drug will be detected and called positive. Similarly, the more frequently a drug is used, the more likely it is to be detected.

False positive results can be avoided by using an appropriate confirmatory test, by using a screening test which has good specificity, and by having the specimen analyzed by a laboratory which has high quality assurance standards. The occurrence of falsely positive test results is usually a result of either human error or cross-reactivity. Cross-reactivity, the phenomenon in which substances other than the drug in question produce a positive result to the test, are more common in the preliminary or screening test than in the confirmatory tests. Tables 25.2 and 25.3 respectively, provide some of the important characteristics of screening and confirmatory drug tests using urine samples.

A common way for the employer to avoid some of the problems in analysis is to establish a cutoff or a threshold level which identifies workers who may have been using a drug within a certain time before the sample was taken. Results above that concentration would be called "positive"; those below would be "negative". A cutoff level for marijuana should be set well above levels resulting from passive inhalation (secondhand smoke). For pre-placement testing, it might be set to detect applicants who used marijuana less than three to four weeks before being sampled. In using such cutoffs, one must still be sure that an illegal or undesirable substance from a workplace health and safety standpoint that has in fact been detected, not an innocent containment or a prescribed medication that is cross-reacting in the test.

Table 25.4. Approximate Duration of Detectability of Selected Drugs in Urine

Note: Interpretation of the duration of detectability must take into account many variables, such as drug metabolism and half-life, subject's physical condition, fluid balance and state of hydration, route and frequency of ingestion. These are general guidelines only.