False Positive—The Reality of Workplace Drugs in America
It isn’t what you recently heard. A special investigation by The Fix into the report that American employee drug use has declined 74% since 1988.
This past November 18th marked the 25th anniversary of President Reagan’s signing into law the Drug-Free Workplace Act. The bill required any institution receiving federal funds to establish and maintain an alcohol and drug-free workplace.
The anniversary might have passed without much comment except that one company was quite aware of the date. Quest Diagnostics, the most prominent corporation in the drug testing industry, saw it as an opportunity to grab headlines.
Quest that day issued a self-congratulatory report stating—unequivocally—that its own survey of 125 million drug tests from 1988 to 2012 proved that there was a 74% decline in drug use among American workers since the Drug-Free Workplace Act was signed. This figure was then heralded by a number of media outlets. The Wall Street Journal, for example, used exactly the same headline as the Quest press release, stating simply:
“Drug Use Among American Workers Declined 74% Over Past 25 Years”
The Journal then cited the Quest press release almost verbatim without undertaking its own closer analysis of the data.
“Overall,” the Journal reported straight from the press release, “3.5% of samples came back positive last year compared with 13.6% in 1988. The vast majority of tests, around 75% in recent years, were conducted for pre-employment screening. The rest were administered following accidents, after employers suspected drug use or as part of regular testing regimens.”
The Quest press release left no doubts that the company was making its bold claim for the entire U.S workforce and not just for Quest's sample of it. It also offered fairly minimal qualifications to its findings, not mentioning major factors that might skew even its own report on those workplaces for which it had some evidence. Instead, its most significant qualification to the news was: “. . .although the rate of positive test results for certain drugs, including amphetamine and opiates, continues to climb."
It then added: ". . .according to a landmark analysis of workplace drug test results released today by Quest Diagnostics (NYSE: DGX), the world’s leading provider of diagnostic information services.” (Quest conducts more than six million workplace drug tests annually, reported $7.4 billion in revenue last year and claims to service 30% of the adult American public with a wide variety of laboratory services, including drug testing.)
It would be a remarkable feat in workplace performance if 74% was an accurate figure. Unfortunately, on closer scrutiny, 74% turns out to be a “false positive.”
A careful inquiry into the details of the Quest study by The Fix reveals the following:
- Few workplaces even test for the widely-used new drugs defined by the DEA as currently threatening America’s health and safety, and so they are excluded from the Quest survey.
- Many employers do not even have a drug-testing program.
- The drugs actually being tested are not tested at uniform sensitivity levels.
- There is no complete uniformity in what drugs and how many different drug types are actually tested for by the employers who do test for drugs, and the Quest survey only includes the tests employers request. Most employers do not test for all drug types.
- Quest put itself forward as one company speaking for the entire American workplace based only upon its own large but hardly definitive sample.
AN EVEN CLOSER LOOK AT THE QUEST SURVEY REVEALS….
There are numerous and subtle factors that make up the world of drug testings in America. Many people applying for a job think you pee in a cup and cross your fingers that your last imbibe of marijuana moved out of your system; or they pray that the meds they are taking - over-the-counter and otherwise - don't create a false positive.
The varieties of contingencies in the world of drugs and drug tests are in fact extensive and complex - as is inevitably any attempt to measure a large chunk of the population's use of the scores of "Illicit" drugs out there along with the "licit" drugs that have gone black market.
Among the host of data influencing factors are where samples are collected, where they are "read" - it can be instantly like a pregnancy test or at the lab - and what drugs are being tested for and at what levels. Then there are the issues of the chain of custody of the samples, the ability of people to cheat on their tests, the facts that employers treat different drugs with different levels of leniency and may even throw away positive tests of the "lenient drugs."
Beyond this there's the reality that different employers might use tests for say, heroin, that are set at a different sensitivity level of detection than the company across the street uses. Some firms care to test for black market prescription drugs, the vast majority don't. Some want to screen for many drugs; most want to go with the basics, often for cost reasons. Some people fail tests, clean up, and then pass a test with a different employer. No data can track that. It goes on and on.
All this a company like Quest needs to take into account in any data survey it releases to the country if it wants it to be credible.
Presumably aware of all these factors, Quest notably handles one troubling issue by omission. That is, it doesn’t count in its survey data an untold number of “instant results” urine specimens that employers then send Quest for legally required follow-up testing with more sophisticated lab technology. Quest omits these numbers from its survey of American drug use on the very reasonable grounds that it has no way of knowing by comparison how many workplace instant results tests per year came up negative or how the employer handled the "chain of custody" of the instant tests.
On the same grounds, Quest also excludes all test results submitted by employers who use a mix of instant results tests and standard urine collection devices.
Scientifically and statistically, this makes sense. Yet it leaves hanging the question: how much of the population's test results - positive and negative - are thereby not factored into the broad statement of 74% improvement?
Asked whether the complete instant results test information would skew the survey if known, one executive told The Fix that there were a negligible number of such uncounted tests sold by Quest each year. Further questioning of Quest’s chief testing scientist, Dr. Barry Sample, revealed that, in fact, there are “substantially less than one million” such uncounted instant results units sold by Quest (the exact number is “proprietary”). Those test cups that are returned are omitted from the database, Dr. Small said, and no count is kept of how many.
Obviously, a large number might alter the glowing survey results if not offset by a known number of negative tests. No number at all leaves the survey to be judged on how Quest treated most of the other complicating factors in the drug testing universe. And that's where the problems with the Quest pronouncement begins.
WHAT THE GOVERNMENT DOESN’T REQUIRE
One of those factors is who must obey government rules and who can do what they want re drug testing. Hugely relevant to the 74% claim is the fact that the federal government issues guidelines naming exactly the drugs to be tested for use by federal workers who are in “safety-sensitive” positions. The government does not otherwise require private sector employers who are not receiving federal funds to test for drugs. The number of employees not being tested therefore is a guesswork moving target.
Even so, one unverified survey claimed that while 84% of workplaces conduct pre-hire screening, only 39% did random follow-up screening of hired employers. Even assuming this survey was accurate, that would leave 16% of job seekers not tested, and huge numbers of people never tested once hired.
These tens of millions of regularly untested workers, if counted by Quest, would clearly skew any survey one way or the other. Quest doesn't account for them in its data base because it can't - but it gives the impression in its public relations announcements that it has.
Equally Alice in Wonderland upside down is the fact that a majority of private employers in the U.S, according to Quest itself, simply ignore the latest federal instructions as to the sensitivity levels they are to use in the first round of drug tests of would-be employees or of already hired employees. Instead, this majority relies on older, pre-2010 test standards with a much higher detection threshold. This would be the equivalent of a police breath test for alcohol set at, say, 1.5 rather than the .08 common in many states, including California.
How many additional people would be found to be using drugs if the stricter standards were applied across the board?
One clue comes from Quest’s report that amphetamine usage has tripled since 1988, with the largest jumps appearing after the federal government changed its guidelines in 2010 to require a sensitivity level for the first round of testing at 500 ng/ml vs. the earlier standard for amphetamines of 1000 ng/ml.
Morphine also showed an increase of 34% between 2005-2012 in the first round of testing.
Accordingly, Quest's statement that there was a 74% decline in drug usage really means that there was a 74% decline only in the tests that were included in the database. These tests, of course, only recorded "positives" at whatever level an employer customer of Quest's chose to use from the available range.
(Note here that the federal government sensitivity levels on the first round of tests are not zero but range from a low of 10 ng/ml for the heroin metabolite to 2000 ng/ml for codeine and morphine. The federal standard used to be 300 ng/ml on the initial test for codeine and morphine. These were dramatically changed when both employers and employees complained that standards were too stringent.)
Quest’s admission to The Fix that it includes in its database the less stringent sensitivity levels that many employers still use, adds to the mish-mash of conflicting and incomplete data that goes into its Drug Testing Index (DTI) on which the company bases its claim that workplace drug use has dramatically fallen.
DESIGNER DRUGS AND THE DEEPER MEANING OF JUST WHICH DRUGS ARE SCRUTINIZED
Another major consideration in measuring drug use in the workplace is exactly which drugs are being tested for. All current first round urine drug tests screen for a “panel” of drugs. These tests are generally limited to 4 or 5 panels that cover the 20 most common drugs and their derivatives.
Since 2010, only amphetamine, cocaine, codeine, morphine, PCPs, 6- Acetylmorphine (a heroin metabolite) and MDMA (ecstasy), are included in the federal guidelines. Ignored is the explosion of drug types and subtypes over the last 20 years.
It would require at least a dozen panels to detect all the licit and illicit drugs currently available to the American employee. Such extended testing by employers is rare.
Quest concedes it only tests for those drugs employers request – and many employers seek to save money by limiting the number of drugs on the panels. If every drug was tested for at the federal guidelines level, obviously the 74% figure would not stand up.
Nor does Quest’s report capture data for use/abuse of what’s known as “designer drugs,” which are a growing concern to the U.S. DEA. According to the 2013 National Drug Threat Assessment (NDTA) Summary issued November 18, 2013, “The abuse of synthetic designer drugs— and the increasing availability of these drugs— has emerged as a serious problem in the United States over the past few years.”
There are seven classes of synthetic designer drugs. They are cannabinoids, phenethylamines, phencyclidines or arylcyclohexamines, tryptamines, piperazines, pipradrols or N-Ring systems, and tropane alkaloids. The number and the type of synthetic cannabinoids have increased exponentially since 2008 as evidenced by the number of reports submitted to the National Forensic Laboratory Information System (NFLIS).
According to the NFLIS, there were 29,467 synthetic cannabinoid drug reports in 2012, an increase of 1,402 percent from 2009.
Also, the availability of synthetic designer drugs known as “bath salts” rapidly increased between 2010 and 2012, causing severe consequences to abusers. Synthetic cathinones—marketed as “legal alternatives to cocaine or Ecstasy (MDMA)”- emerged in the US designer drug market during 2009.
A quick review of the NFLIS 2012 Annual Report shows soaring use since 2001 of even more drugs that don’t make it to Quest’s DTI. These include clonazepam, buprenorphine and alprazolam, to name a few.
Further clouding the Quest results is the vast expansion of “legal” substances that have found their way into the black market. According to Quest executives, only certain employers ask Quest to test for such widely used painkillers as oxycodone and hydrocodone that are not required to be tested under the federal workplace guidelines. Quest’s DTI reported that, between 2005 and 2012, these “expanded opiate” tests show dramatic increases in positive rates for hydrocodone (an increase of 423%) and oxycodone (an increase of 172%).
Hydrocodone is an ingredient in Vicodin and Norco, and, while widely available in the US, is prohibited for medical use in the UK, the Netherlands, France and Sweden. Oxycodone is an ingredient in OxyContin and Percocet.
Given the very limited number of tests reflected in the DTI, it is impossible to infer from the DTI the degree to which such drug usage is precisely on the rise among the population never tested for them. What is clear is that the Quest press release headline does not account for this unknowable.
WHICH SURVEY TO BELIEVE?
In interviews with The Fix, Quest’s executives defended the integrity of its press release, arguing that Quest’s workplace drug test results and the data reported by Quest mirror the results being reported by the National Survey on Drug Use and Health (NSDUH) and is in line with trends shown in other studies of drug use/abuse in the U.S.
However, on the same day that Quest issued its press release proclaiming 74% improvement in the American workplace, the U.S. Department of Justice and the U.S. Drug Enforcement Administration (DEA) released a very different report, showing a very different picture.
The 2013 National Drug Threat Assessment (NDTA) Summary addressed emerging developments in the trafficking and use of primary illicit abuse substances. The Summary also covered the non-medical use of controlled prescription drugs (CPDs).
It reported: “According to the National Survey on Drug Use and Health (NSDUH), pain relievers are the most common type of CPD taken illicitly and are the CPDs most commonly involved in overdose incidents…Prescription drug abuse continues to be the nation’s fastest growing drug problem and …poses a significant drug threat to the United States…2011 data indicate that 6.1 million people (2.7 percent of the US population) aged 12 or older are current non-medical users of psychotherapeutic drugs.”
Quest’s 2012 data for its upbeat report was similarly based on 6 million drug screens, only using a workplace population vs. the U.S. population at large researched by the NSDUH. Quest acknowledged to The Fix that its data doesn’t include a complete picture of the drugs being used by the U.S workforce similar to the Summary's. The reason? Federal regulations do not require tests for substances found in prescription drugs, and few employers choose to test for these.
Which adds up, of course, to another set of drug users who did not find their way into Quest's data base.
Asked about testing for the full range of opiates, which are an important segment of the little-tested illicit and licit drug market, Quest representatives reported that its customer purchases of an “expanded opiate” test covered only 80,000 (1.6%) of its workplace testing population of 5,000,000. These results were properly incorporated in the DTI data. Separately, Quest has published data showing approximately .9% or 45,000 persons in the general workforce of 5,000,000 tested positive for hydrocodone in 2012.
Hence, out of 80,000 persons subject to the “expanded opiate” drug screen, 45,000 or 56% of the persons so tested, showed positive in 2012 for hydrocodone.
What if the remaining 4,200,000 persons in that population of tested persons had also been tested under an “expanded opiate” platform? Could the results alone potentially be so high as to refute the conclusion that workplace drug use has declined since 1988, even ignoring the other limitations of the Quest study?
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Scratch the surface of drug testing data issued by federal agencies and a different picture of the overall drug usage of the U.S. population emerges.
On the one hand, Quest’s officials in statements to The Fix and presented online in its webinars, insist that Quest’s DTI data mirrors the general trends in the U.S. On the other hand, it would not be incorrect to state that drug use by the U.S. workforce, mirroring the trends in general in the U.S. population, has increased for most drugs available since 1988 and, further, that a not insignificant part of the U.S. workforce is now under the influence of drugs that were not even available in 1988 and are not being monitored by current drug tests.
HOW QUEST RESPONDS TO THE QUESTION OF OVERSTATED AND MISLEADING CONCLUSIONS IN ITS MARKETING AND PR
A reporter and editor from The Fix spent 2.5 hours in telephone interviews with Dr. Barry Sample, Quest’s director of science and technology for its Employer Solutions division, and with Dr. Sample’s supervisor, Bob McCormick, the company’s vice president for Employer Solutions. Additionally, Dr. Sample provided a number of written responses to numerous questions submitted by The Fix.
Both men were helpful and forthcoming about the scientific choices underpinning the Quest study and spelled out some of the very reasonable decisions that had been made toward the integrity of the study. Both also said they supported the official Quest press release which proclaimed itself to be an accurate statement on the U.S. workplace.
At one point in the interview, The Fix representatives notated to both men each of the points in this article refuting their claim that the report was an accurate mirror of the U.S. workforce. The Fix representative then read aloud the headline and opening paragraphs of the Quest press release. It included these statements:
“Today’s Quest Diagnostics Drug Testing Index provides the best evidence to date that the Drug-Free Workplace Act and the public and private initiatives it helped to spur have led to steep declines in drug use among much of the American workforce,” said Laura Shelton, executive director, Drug and Alcohol Testing Industry Association (DATIA). “While more needs to be done to reduce illicit drug use by workers, we should take heart from the tremendous progress employers have made to create safer workplaces for millions of Americans.”
“Key findings from the analysis:
“The positivity rate for the Combined U.S. Workforce declined 74%, from 13.6% in 1988 to 3.5% in 2012.
“The positivity rate for the Federally Mandated, Safety Sensitive Workforce declined by 38%, from 2.6% in 1992 to 1.6% in 2012.
“The positivity rate for the U.S. General Workforce declined by 60%, from 10.3% in 1992 to 4.1% in 2012.
“Despite the declines in overall drug use, the DTI analysis also found that the positivity rate for certain segments of drugs has increased.”
Dr. Sample and Mr. McCormick were then asked how they could possibly justify the press release statements referring to the “Combined U.S. Workforce,” the “Federally Mandated, Safety Sensitive Workforce” and the “U.S. General Workforce” when clearly the Quest data did not apply to the entire workforce and by no means represented all the potential drug usage that was not tested.
“Isn’t there a huge gap between your scientific work and the marketing and public relations of the company?” The Fix asked.
Replied Dr. Sample:
“I can’t speak for how the media outlets represent all the things in our press release. All I can say to you is we have called out all those events and exceptions in our data and in any interviews we have done.”
A Fix representative then pointed out to Dr. Sample that the media was saying exactly what the press release starkly claimed and nothing different. Moreover, that while there were qualifications in the data survey itself (which few media outlets likely read) neither they nor the few qualifications in the press release addressed all the points raised by The Fix. Given all this, did the two men still want to stand behind the press release statement rather than modify it to make it clear that the Quest study and database represent a complex set of assumptions about only the population tested by Quest?
Dr. Sample: “Yes, in its entirety and all the supporting tables and data sets that go with it,….we stand by the data. We believe it to be highly statistically active for those work forces that are doing drug testing. This is the experience they seem to be having and there is a lot of correlation between our data statements and others.”
And were both men aware of the content of the press release and other marketing statements before they were released?
“Yes,” from each of them.
A very different conclusion would be that Quest marketing overrode Quest science with the assistance of both these men.
Confronted with the challenges from The Fix, Mr. McCormick and Dr. Sample noted that drug-place testing programs along with Quest’s DTI are effective “deterrent” tools that steered drug users and abusers away from seeking work at those employers with drug-screening programs.
To whatever degree that may be accurate, it belies the reality that Quest’s marketing is meant to generate even more customers and more drug testing as its role in a drug-industrial-law enforcement and prison complex that thrives on monetizing drug usage. It is a complex that pays far less attention and dollars to altering the underlying reasons why drugs have such a vast role in life-as-we-know-it in the U.S.
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Ellen Batzel, J.D., LL.M , and her companies consult on drug testing matters for physicians, clinics, insurers, laboratories, employers, sober living and rehab centers, and technology development companies. Her companies set up drug testing programs primarily in the pain management therapy sector.