TESTING FOR DRUGS OF ABUSE IN CHILDREN AND ADOLESCENTS

Abstract

The American Academy of Pediatrics continues to believe that adolescents
should not be drug tested without their knowledge and consent. Recent US
Supreme Court decisions and market forces have resulted in recommendations
for drug testing of adolescents at school and products for parents to use
to test adolescents at home. The American Academy of Pediatrics has strong
reservations about testing adolescents at school or at home and believes
that more research is needed on both safety and efficacy before
school-based testing programs are implemented. The American Academy of
Pediatrics also believes that more adolescent-specific substance abuse
treatment resources are needed to ensure that testing leads to early
rehabilitation rather than to punitive measures only.

Background

In 1996, the American Academy of Pediatrics (AAP) published (and reaffirmed
in 2006) a policy statement titled "Testing for Drugs of Abuse in Children
and Adolescents," which opposed involuntary testing of adolescents for
drugs of abuse.1 The policy statement also stated that laboratory testing
for drugs under any circumstances is improper unless the patient and
clinician can be assured that the test procedure is valid and reliable and
patient confidentiality is ensured. This policy statement was published
shortly after a 1995 US Supreme Court ruling (Vernonia v Acton [515 US
646]) held that random drug testing of high school athletes is
constitutional. Since that time, national interest in school-based drug
testing has increased. In June 2002, the US Supreme Court, in a 5-to-4
decision, ruled that public schools have the authority to perform random
drug tests on all middle and high school students participating in
extracurricular activities (Board of Education v Earls [536 US 822, 122 S
Ct 2559, 153 L Ed 2 days 735 {2002}]). Writing for the majority, Justice
Clarence Thomas wrote, "Testing students who participate in extracurricular
activities is a reasonably effective means of addressing the School
District's legitimate concerns in preventing, deterring and detecting drug
use." Shortly after this Supreme Court ruling, the President's Office of
National Drug Control Policy published a guidebook designed to encourage
schools to incorporate drug-testing policies for all students.2

Interest in drug testing of adolescents reaches beyond public schools.
During recent years, a substantial number of companies have begun to market
home drug-testing products directly to parents.3 Products that identify
alcohol and drugs in urine, saliva, and hair are now available at retail
outlets and via the Internet. Pediatricians may be asked about home drug
testing by parents of their adolescent patients. Pediatricians involved in
school health may be asked to assist in implementing school-based
drug-testing programs. For these reasons, the Committee on Substance Abuse
has conducted a review of the available science on drug testing of
adolescents and is issuing this addendum to the 1996 policy statement.
Although much has been written on the pros and cons of testing adolescents
for drugs, relatively little has been published in peer-review scientific
journals.

Benefits And Risks Of Drug Testing In Schools And At Home

School- and home-based drug testing poses a number of potential benefits
and risks. On the positive side, both procedures would likely increase the
number of adolescents who are screened for use of illicit drugs.
Population-based screening also offers the potential for providing early
intervention and treatment services to more adolescents. The Office of
National Drug Control Policy guidebook states: "Results of a positive drug
test should not be used merely to punish a student. Drug and alcohol use
can lead to addiction, and punishment alone may not necessarily halt this
progression. However, the road to addiction can be blocked by timely
intervention and appropriate treatment."2 Proponents of drug testing also
claim that the existence of a school-or home-based drug-testing program
will help adolescents refuse drugs and provide legitimate reasons to resist
peer pressure to use drugs, although these claims are not yet proven. On
the negative side, drug testing poses substantial risks--in particular, the
risk of harming the parent-child and school-child relationships by creating
an environment of resentment, distrust, and suspicion.4 In addition to the
effects on the individual adolescent, the safety and efficacy of random
drug testing requires additional scientific evaluation. Broad
implementation of random drug testing as a component of a comprehensive
drug-use prevention program should await the results of these studies.

Currently, there is little evidence of the effectiveness of school-based
drug testing in the scientific literature. Goldberg et al5 compared 2
schools, one of which implemented a mandatory drug-testing program for
student athletes and the other of which did not. They found at follow-up
that the use of illicit drugs, but not alcohol, was significantly lower
among athletes who were drug tested. However, they also found that athletes
who were drug tested experienced an increase in known risk factors for drug
use, including an increase in normative views of use, belief in lower risk
of use, and poorer attitudes toward the school.

A larger observational study by Yamaguchi et al,6 which analyzed data from
the national Monitoring the Future study, found no association between
school-based drug testing and students' reports of drug use. Among the
nationally representative group of more than 300 schools, drug testing was
most commonly conducted "for cause" (ie, suspicion; 14% of schools) and was
far less commonly required for student athletes (4.9% of schools) or
students participating in other extracurricular activities (2.3% of
schools). Regardless of the reason it was performed, drug testing was not
significantly associated with reduction in the use of marijuana or any
other illicit drug among students in any grade studied (ie, 8th, 10th, or
12th grade). However, 1 observational study is not sufficient to establish
causation or lack of causation. In addition, no detail was provided
regarding the extent of drug testing in the study schools, and at some
schools, it may have been minimal. Further scientific investigation is
warranted.

Laboratory testing for drugs of abuse is a technically complex procedure.
To ensure the validity of the specimen, urination must be directly
observed, which is a potentially embarrassing procedure for all involved,
or the collector must use a fairly complex and expensive federally approved
protocol, which involves documentation of a continuous chain of custody in
handling and includes temperature testing and controls for adulteration and
dilution.7 Few schools will have sufficient staff with proper training to
implement these costly procedures, and a recent survey of pediatricians,
adolescent medicine specialists, and family physicians found that few
physicians will be able to help, because less than 25% are familiar with
proper procedures for collection, validation, and interpretation of urine
drug tests.8 Similarly, most parents cannot implement the federal
collection protocol and, for ethical and developmental reasons, should not
directly observe their teenaged children urinating. Although drug testing
of hair and saliva is available, validity has not been firmly established.
Questions remain regarding how passive exposure to drugs as well as
differences among races and sexes can affect hair testing.9-12 In addition,
hair testing is more likely to be useful in detecting historical drug use
rather than current use.9,13 Oral fluid testing (ie, saliva or oral swab),
by contrast, gives a more accurate picture of current use.14 However,
accuracy of oral fluid testing varies across drugs of abuse. Oral fluid
testing performs well in detecting the use of opiates and methamphetamine,
but it performs poorly in detecting the use of benzodiazepines and
cannabinoids.15-17

Interpretation of drug tests can also be complex. School staff members
and/or parents need to be able to assess possible false-positive results,
especially when screening test results are positive for amphetamines or
opioids. Over-the-counter cold medications containing pseudoephedrine can
cause false-positive screening results for amphetamine, although follow-up
testing with gas chromatography and mass spectrometry is highly specific
and can reliably confirm the presence of amphetamine.17 Ingestion of foods
that contain poppy seeds makes interpretation of drug testing more
difficult, because it can cause screening and gas chromatography and mass
spectrometry results to be falsely positive for morphine and/or codeine.18

It is fairly easy to defeat drug tests, and most drug-involved youth are
all too familiar with ways to do so. Even properly collected specimens must
have checks for validity (eg, urine specific gravity and creatinine),
because the easiest way to defeat a drug testing is by simple dilution.19
Even when properly collected and validated, urine drug tests yield very
limited information. With the exception of marijuana, the window of
detection for most drugs of abuse is 72 hours or less.19 Therefore,
negative test results indicate only that the adolescent did not use a
specific drug during the past several days. Even adolescents with serious
drug problems may have negative test results on most occasions.20 Standard
drug-testing panels also do not detect many of the drugs most frequently
abused by adolescents, such as alcohol, ecstasy
(3,4-methylenedioxymethamphetamine [MDMA]), and inhalants, and information
on the limitations of screening tests and ways to defeat them is widely
available to adolescents via the Internet.3 Widespread implementation of
drug testing may, therefore, inadvertently encourage more students to abuse
alcohol, which is associated with more adolescent deaths than any illicit
drug but is not included in many standard testing panels. Mandatory drug
testing may also motivate some drug-involved adolescents to change from
using drugs with relatively less associated morbidity and mortality, such
as marijuana, to those that pose greater danger (eg, inhalants) but are not
detected by screening tests. No studies have yet been conducted on this
important issue. Safety of randomly testing adolescents for the use of
drugs should be scientifically established before it is widely implemented.

Drug testing may also be perceived by adolescents as an unwarranted
invasion of privacy. A policy statement is being developed by the Council
on School Health on the role of schools in combating substance abuse. It
will discuss the potential risks of school-based drug testing and
alternative approaches to school-based prevention of drug abuse. Few
physicians support school-based testing of adolescents for drugs; a
national survey of physicians (pediatrics, family medicine, and adolescent
medicine) found that 83% disagreed with drug testing in public schools.20

A key issue at the heart of the drug-testing dilemma is the lack of
developmentally appropriate adolescent substance abuse and mental health
treatment.21 Adequate resources for assessment and treatment must be
available to students who have positive test results. However, many
communities lack substance abuse treatment services dedicated to
adolescents, and adult substance abuse treatment programs may be
inappropriate and ineffective for adolescents.21 Federal support for
school-based drug testing should include an allocation of resources that
will facilitate greater access to adolescent substance abuse treatment.

Additional Conclusions And Recommendations

1. The AAP supports rigorous scientific study of both the safety and
efficacy of school- and home-based drug testing of adolescents.

2. The AAP recommends that school- and home-based drug testing not be
implemented before its safety and efficacy are established and adequate
substance abuse assessment and treatment services are available.

3. The AAP encourages parents who are concerned that their child may be
using drugs or alcohol to consult their child's primary care physician or
other health professional rather than rely on school-based drug screening
or use home drug-testing products.

4. The AAP recommends that health care professionals who obtain drug tests
or assist others in interpreting the results of drug tests be knowledgeable
about the relevant technical aspects and limitations of the procedures.

Committee on Substance Abuse, 2005-2006:

Alain Joffe, MD, MPH, Chairperson

Mary Lou Behnke, MD

*John R. Knight, MD

Patricia Kokotailo, MD

Tammy H. Sims, MD, MS

Janet F. Williams, MD

Past Committee Member

John W. Kulig, MD, MPH

Liaison :

Deborah Simkin, MD

American Association of Child and Adolescent Psychiatry

Consultants:

Linn Goldberg, MD

Sharon Levy, MD, MPH

Staff:

Karen Smith

Council on School Health, 2005-2006

Robert D. Murray, MD, Chairperson

Barbara L. Frankowski, MD, MPH

Rani S. Gereige, MD, MPH

*Cynthia J. Mears, DO

Michele M. Roland, MD

Thomas L. Young, MD

Linda M. Grant, MD, MPH

Daniel Hyman, MD

Harold Magalnick, MD

George J. Monteverdi, MD

Evan G. Pattishall III, MD

Liaisons:

Nancy LaCursia, PhD

American School Health Association

Donna Mazyck, MS, RN

National Association of School Nurses

Mary Vernon-Smiley, MD, MPH

Centers for Disease Control and Prevention

Robin Wallace, MD

Independent School Health Association

Staff:

Madra Guinn-Jones, MPH

Footnotes:

All policy statements from the American Academy of Pediatrics automatically
expire 5 years after publication unless reaffirmed, revised, or retired at
or before that time.

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