Dr. Stalcup: The tox screen is underused in psychiatric practice. A urine tox screen should be a standard part of all initial evaluations, because we know that drug use is a major confounding variable in psychiatric treatment. When you look at people who aren’t doing well, you often see two kinds of problems, both of which can be diagnosed with a tox screen. The first problem is that often drug and alcohol use is interfering with good outcomes in psychiatric treatment, and the other problem is unrecognized tolerance.
CATR: So how do we use drug testing for diagnosing hidden substance abuse problems?
Dr. Stalcup: I think of a tox screen as a diagnostic test. The defining characteristic of addiction is continuing to use substances in an out-of-control way in the face of adverse consequences. The question being asked by the testing is, in the face of adverse consequences, can this person not use? And if someone under scrutiny is unable to not use, then we feel that person should be evaluated for treatment of addiction.
CATR: Guide us through your process for approaching patients about drug screens. It can be an uncomfortable topic to broach.
Dr. Stalcup: There are very non-intrusive ways for us to get at drug and alcohol use without driving the patient out the door. If I’ve been seeing a patient for a month and I felt there was no progress, I might say: “How often in a month do you get a buzz?” Not how often they “drink,” because we are more interested in whether they’ll disclose intoxication. I’ll explain to them that research shows that drug or alcohol use might be interfering with what they’re trying to achieve in terms of symptom management. Testing is presented as value-neutral and a simple diagnostic screen. Despite this non-judgmental approach, some patients will be anxious and embarrassed, and if so I reassure them that no punishment will result from a positive test. When recommending the test you can say something like, “It’s part of our practice to get urine drug screens. We need to know what’s in someone’s system. If there’s nothing there, that’s good, and if there is, then we will talk about it.”
CATR: What do you do if there’s pushback from the patient?
Dr. Stalcup: You may well get pushback and you say this is just a diagnostic test. We are trying to see what’s in your system so we can better design a treatment plan for you. I will share with them that sometimes it is hard to disclose what is in your system and that they are not aware that something they might be taking is interfering with their antidepressants and medicines. So while this can be a source of conflict, I’m surprised at how rarely it actually occurs. Sometimes patients are actually relieved they don’t have to tell us what they’ve been using. I try to roll with their resistance as best I can.
CATR: What about the specific case of an unwilling teenager being brought in by a parent for testing?
Dr. Stalcup: As with adults, we try to uncover the source of resistance. We ask, can you not use? Because if you cannot, it is very likely that your treatment is not going to go well. Patients, particularly adolescents, don’t like being controlled and the reality of drugs is that once you’re addicted, they control you. So we challenge them: if you can stop using, you’re in charge. If you intend to not use and are using, the drug is in control. Teens don’t like being told what to do and get furious and often fail the experiment. And then it opens the door to what they can do to evaluate and assess their use.
CATR: You also mentioned that a big reason for ordering tox screens is to check for unrecognized tolerance. What do you mean by that?
Dr. Stalcup: A common presentation in addiction and in psychiatry practice is a distressed patient, not benefiting from medication management; often they disclose a long history of sedative-hypnotic use (benzodiazepines, muscle “relaxants,” sleep aids, and alcohol). However, many patients are unaware of any problem stemming from their sedative-hypnotic use, and either don’t disclose their use or are reluctant to disclose the information for fear that the drug will be discontinued (which for many is a truly frightening process). In this context, a urine drug screen is a valuable diagnostic tool, and opens the door to more therapeutic options. It turns out drug withdrawal is highly kindled. Every time someone goes through withdrawal and it isn’t properly managed, the nervous system is sensitized (“kindled”) so that withdrawal gets worse over time. Once taken off of the sedative-hypnotic drug, these patients are often left with a high withdrawal symptom burden, and become refractory to medication management. We now know this is because of withdrawal management in which symptoms remain high during the detox and don’t remit after substitution medications are discontinued. I’m really troubled by quick and dirty detox. The drug is not the enemy so much as the withdrawal is the enemy, and we aim to mitigate that. A drug screen revealing benzodiazepine or sedative-hypnotic use can both help understand why the course of treatment is not going well, but also uncover a source of physiological and psychological distress to the patient. We feel strongly that psychiatrists need to look at unrecognized tolerance because it runs loose through so many psychiatric practices and is not that hard to diagnose. We strongly encourage people to rethink the issue of whether benzos might be contributing to treatment failure.